Failure to Report Alleged Neglect After Delay in Following MD Transfer Order
Summary
The facility failed to report an allegation of neglect to the New Jersey Department of Health (NJDOH) after a resident with multiple cardiac conditions experienced a significant change in condition and a physician’s order to send the resident to the hospital was not promptly carried out. The resident had diagnoses including systolic congestive heart failure, atrial fibrillation, and hypertension, and a comprehensive MDS showed moderate cognitive impairment with a BIMS score of 11/15. On the morning in question, nursing documentation reflected that the resident had loose stools with very foul-smelling, dark fluid, and vital signs showed a blood pressure of 73/47 mm Hg, which is below the normal adult range. According to a late-entry physician progress note, the physician gave a verbal order at 9:33 AM to the Assistant Director of Nursing (ADON #2) to send the resident to the emergency room due to low blood pressure. A late-entry provider note by ADON #2 stated that after being notified by a float nurse, ADON #2 assessed the resident, found them responsive without labored breathing, repositioned them, attempted to contact the physician, notified the DON for assessment, and documented that the physician gave an order to send the resident out at 9:59 AM, after which 911 was activated and the resident was transferred while still responsive. However, in an interview, the physician stated that when ADON #2 called around 9:30 AM, she instructed that 911 be called and the resident be sent to the ER, and when she arrived at the facility at 10:00 AM, she assumed the resident had already left. The physician further reported that at about 10:10 AM she was informed by an LPN that the resident was still in the facility with a further decreased blood pressure of 64/34 mm Hg, and that staff told her they were waiting for her to come in. The physician stated that ADON #2 told her they were waiting for labs to be drawn before calling 911, which the physician indicated was not appropriate for the resident’s condition, and only then was 911 called. The DON reported that facility leadership was not made aware of the delay in sending the resident to the hospital until after the resident expired at the hospital, and that ADON #2 had not informed her despite documenting in a late-entry note that the DON had been notified. The Licensed Nursing Home Administrator acknowledged that the event should have been reported to NJDOH, and review of facility policies showed that allegations or suspicions of neglect and resident safety events were required to be promptly reported to regulatory authorities, which did not occur in this case.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to report an alleged misappropriation of resident funds. A resident with COPD, anxiety, and PTSD reported $1,600 missing and believed another resident took it, but the SSD reportedly said it was too long ago to investigate. The CNO recalled hearing about missing funds from a family member but did not pursue it, and the CEO stated the allegation should have been reported to the State Agency.
Failure to report alleged sexual abuse within required timeframe. A resident with intact cognition and significant ADL dependence alleged that a CNA raped them during incontinence care; the resident later described possible penetration and burning, while the CNA said they only provided brief care and applied ointment. The family member contacted law enforcement and requested hospital transfer, but facility leadership did not report the allegation to DOH within 2 hours, stating they believed the allegation had changed to rough handling and did not meet the reporting threshold.
Failure to Immediately Report Abuse Allegations and Injury of Unknown Origin: Staff did not immediately report two resident-to-resident sexual abuse incidents involving one resident touching two others, and staff also did not immediately report bruising of unknown origin on another resident. A CNA redirected the resident during the abuse incidents but did not notify the charge nurse, DON, or Administrator, and an RN and LPN did not escalate the bruising after assessing it and hearing it described as handprint-like. The delayed reporting prevented timely initiation of the abuse investigation process and resident assessment.
Failure to Report Alleged Physical Abuse: A resident alleged that two CNAs were rough while repositioning them in bed and that the resident’s head was bumped into the headboard, causing pain. One CNA confirmed the head bump occurred during care, and the administrator stated the abuse allegation and failure to report were substantiated because the staff did not report the incident immediately.
Failure to Timely Report Allegation of Abuse: A nurse witnessed one resident touch another resident inappropriately, but the incident was not reported within the required timeframe. The LPN separated the residents and addressed boundaries with the resident involved, but did not report the event because she believed the RN would notify the DON. The DON and Administrator later stated the incident had not been reported immediately as required.
Failure to Immediately Report Verbal Abuse Allegation: A CNA was heard using foul and disrespectful language toward a cognitively impaired resident during care, but the allegation was not reported immediately to the DON/Administrator. The witness delayed reporting for several hours, and the DON, ADON, and Administrator confirmed the report was not made until later that morning. The resident had severe cognitive impairment, was dependent on staff for care, and received nutrition via GT.
Failure to Report Alleged Misappropriation
Penalty
Summary
The facility failed to ensure an allegation of misappropriation was reported to the State Agency as required for Resident #23, who was admitted with diagnoses including COPD, anxiety, and PTSD. Resident #23 stated that approximately two months before the survey, he reported $1,600.00 missing to the Social Services Director and believed another resident had taken the money. He reported that the SSD asked how long ago it happened, and when he said about one and a half months earlier, he was told it had been too long ago to investigate. During the survey, the SSD did not respond to a call for interview, the CNO stated she recalled a family member mentioning the missing funds but did not ask further questions, and the CNO said the allegation was never made directly to her or facility staff. The CEO stated the allegation should have been reported to the State Agency.
Failure to Report Alleged Sexual Abuse Within Required Timeframe
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse was reported to the New York State Department of Health and local law enforcement within two hours of the allegation. The deficiency involved one resident who had diagnoses including obstructive and reflux uropathy, hemiplegia, and hemiparesis following cerebral infarction. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the care plan showed the resident required assistance with ADLs, including two staff members for transfers and toileting and extensive assistance for dressing, bathing, grooming, and bed mobility. According to the facility’s incident report, the resident told an LPN that they had been raped by a CNA while receiving care. The resident later described that the CNA entered the room to change a wet brief, applied cream to the hip and then to the anus and vaginal area, and that they felt something enter the anus and vagina while asking the CNA to stop. The CNA stated they provided incontinence care and applied A and D ointment to the perianal area, and the video review showed the CNA entered the room at 4:43 AM and exited at 5:19 AM. The resident’s family member reported that the resident called them, said to come immediately, and later stated that a staff member had raped them. The family member contacted law enforcement and requested hospital transfer. Facility leadership acknowledged awareness of the allegation but did not report the alleged rape to the Department of Health, stating they believed the allegation changed to rough handling and did not meet the reporting threshold. The DON, Administrator, and Social Worker each described differing understandings of the allegation and reporting status, and the report states there was no documented evidence that the allegation was reported to local law enforcement or the Department of Health within two hours as required.
Failure to Immediately Report Abuse Allegations and Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure staff immediately reported allegations of abuse to administration for two separate resident-to-resident sexual abuse incidents involving three residents. One CNA witnessed Resident #3 inappropriately touch Resident #1’s breasts while Resident #1 was asleep, and later saw Resident #3 reach under Resident #2’s blanket while Resident #2 pushed the hands away and told Resident #3 to stop. The CNA redirected Resident #3 during both incidents but did not immediately notify the charge nurse, DON, or Administrator. The incidents were later identified by the DON through electronic medical record alerts, and the DON and Administrator stated they were not notified when the events occurred. The facility also failed to ensure staff immediately reported an injury of unknown origin for Resident #4. Two CNAs observed multiple bruises, including bruises resembling handprints, while providing care and notified an RN and LPN. The RN assessed the resident and documented bruising of unknown origin, but neither the RN nor the LPN notified the DON or Administrator at that time. The LPN stated the CNAs were discussing the bruises with the RN and therefore did not contact higher management, while the RN did not believe the bruising was concerning because the resident had fragile skin and was on a blood thinner. Because the allegations were not immediately escalated, the facility’s abuse investigation process was delayed, including resident assessment and collection of investigative information. For Resident #4, the DON stated the resident had already been transferred to the hospital before the facility initiated an abuse investigation and could not be assessed as part of the initial investigation. The Administrator acknowledged that facility protocol requiring immediate reporting of abuse allegations was not followed in both events.
Failure to Report Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure an allegation of physical abuse was reported for one resident. A written statement from the resident said that a night shift CNA and the CNA’s helper slid the resident up in bed and rammed the resident’s head into the headboard, causing the resident to holler out in pain. The resident later stated that the staff had hurt them by being rough. An email statement from one CNA said that the resident’s head bumped the headboard while the resident was being pulled up in bed after a change, and that the CNA apologized and asked several times if the resident was okay. Employee counseling records showed two CNAs were terminated for failure to report an allegation of abuse. The administrator stated the abuse allegation and failure to report were substantiated after the facility investigation, and stated the staff should have reported the incident immediately when the resident said they were hurt.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the regulated timeframe for 2 of 27 residents reviewed for abuse. The facility policy stated that suspected abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source must be reported immediately, defined as within 2 hours for allegations involving abuse or serious bodily injury, or within 24 hours for allegations that do not involve abuse or serious bodily injury. R15 was admitted with diagnoses including dementia, essential hypertension, depression, and pure hyperglyceridemia, and R14 was admitted with diagnoses including hypertension, left above-the-knee amputation, anxiety disorder, neurogenic bladder, and COPD. Staff interviews and record review showed that a nurse witnessed R14 touch R15 inappropriately in the dining room on 06/22/26, with the Social Services Director later stating the incident was reported to her on 06/24/26. The LPN stated she was told by an RN that R14 touched R15 inappropriately, separated the residents, discussed boundaries with R14, and did not report it because she thought the RN would report it to the DON. The DON stated she was made aware on 06/24/26 of an incident that had occurred a couple of nights earlier, and the Administrator stated the nurse assigned to the residents did not report the incident immediately.
Failure to Immediately Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse was reported immediately to the Administrator when a CNA was witnessed using foul language at the bedside within earshot of a resident. The deficiency involved one resident reviewed for abuse/neglect and was based on interviews and record review showing that the allegation was not reported right away, but instead was brought to the DON hours later the same morning. The resident involved was a female with multiple serious diagnoses, including respiratory failure, a stage 2 sacral pressure ulcer, encephalopathy, anemia, diabetes, malnutrition, non-Alzheimer's dementia, depression, hypertension, severe chronic kidney disease, difficulty walking, failure to thrive, leukemia in remission, and a bone marrow transplant history. Her quarterly MDS showed a BIMS score of 07, indicating severe cognitive impairment, with delusions and inattentiveness. She was dependent on staff for personal hygiene, dressing, toileting, positioning, and transfers, was always incontinent of bowel and bladder, and received nutrition through a feeding tube. A CNA reported that while assisting the resident with care, another CNA repeatedly used disrespectful language toward the resident, including calling her a derogatory name while the resident was in the room and within hearing distance. The witness said she did not report the allegation immediately because she was thinking about it and did not want to jeopardize the other CNA's job, and she ultimately reported it later that morning to the DON. The DON and ADON confirmed the allegation was not brought to the Administrator until hours after it occurred, and the Administrator stated she was unaware of the behavior until the report was made. The facility records also showed policies requiring immediate reporting of suspected abuse and defining verbal abuse as communication within hearing distance that can cause humiliation, intimidation, fear, shame, agitation, or degradation.
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