Failure to Timely Report Suspected Abuse Allegations: The facility did not timely report suspected abuse involving a resident and CNA, and did not report a resident-to-resident altercation until the state agency brought it to its attention. Records showed one resident with mood disorder, SI, anxiety, and depression reported a physical fight with a CNA and had scratches, while two other residents were involved in an incident where one resident was found over the other and the injured resident had a bruise and skin tear. Staff and the DON discussed the events internally, but the administrator determined one allegation was not reportable and the other was not abuse, despite policy requiring immediate reporting of suspected abuse.
A resident with multiple chronic conditions and moderate cognitive impairment was involved in an incident during a transfer when an LPN tapped or hit her leg while staff tried to reposition her. The resident’s family later reported that the nurse had struck her legs, and staff interviews confirmed the allegation was not reported immediately as required. The facility’s abuse policy required reporting within two hours, but the allegation was not escalated until the next morning.
Failure to Report Allegation of Abuse to State Agency: A resident with psychiatric diagnoses and intact cognition accused an LPN of throwing water on her during an episode of altered mental status, drowsiness, slurred speech, and belligerence. The incident was treated as an allegation of abuse, but the record showed no report to the state agency within the required timeframe, and the DON acknowledged it should have been reported within 2 hrs per policy.
Failure to timely report abuse investigation results: A CNA heard a scream and found one resident had pulled another resident’s hair after the other resident repeatedly entered the room. The residents were separated, no visible injuries were noted, and the provider, DON, case manager, families, and police were notified. However, the facility could not provide evidence that the completed investigation findings were submitted to the State Survey Agency within the required 5-working-day timeframe, and the State Agency tracking system showed no record of the submission.
Failure to Timely Report Resident-to-Resident Abuse: Two residents with cognitive impairment and shared-room conflict were involved in an altercation in which a nurse observed the male resident grabbing the female resident's wrist while she tried to pull away, and the female resident said he hit and grabbed her. Although the DON and administrator acknowledged the event was reportable and required immediate reporting, the incident was not reported to the state agency within the required timeframe and no investigation was completed for the event.
Failure to timely report an allegation of neglect: a Nursing Student reported that a CNA had not provided cares and residents were left wet and unchanged, and the RN relayed the complaint to facility leadership. The DON and SSD acknowledged the complaint was shared internally, but the former Administrator denied receiving it and did not report it to the SA within the required 24-hour timeframe. The facility’s policy required prompt reporting of suspected neglect and a follow-up investigation report within 5 working days.
Failure to Report Alleged Resident-to-Resident Abuse: A resident-to-resident incident involving two cognitively impaired residents was not reported to all required agencies after staff observed one resident swat at and appear to punch another resident in the leg. An LPN contacted the DON and police, but the ADON later reviewed video and concluded there was no contact, and the DON believed reporting was unnecessary if contact could not be confirmed. The facility policy required suspected or alleged abuse to be reported immediately to the Administrator and other officials, including the State Survey Agency and APS.
Failure to timely report resident-to-resident abuse allegation: A resident with dementia and severe cognitive impairment was found with a bruise after another resident entered the room, grabbed the resident’s arm and leg, and staff separated them. The other resident had a hx of wandering, agitation, and combative behavior, and staff interviews confirmed the interaction could be considered abuse. The covering DON/administrator reported the event to the State Agency the next day instead of within the required 2 hours, stating there was no harm done.
A cognitively intact resident with multiple medical conditions allegedly experienced abuse involving someone placing a pillow over the face with a sour substance. A complainant reported this allegation by phone to the Social Services Director, who, contrary to facility policy and staff expectations, did not notify the SA, APS, Ombudsman, or the Administrator because she did not believe abuse had occurred based on the medical record. Other staff, including a CNA, an LPN, the DON, and the Administrator, reported that their understanding of policy was that all abuse allegations must be reported within specified time frames, but they were not informed of this allegation, and no self-report was made to state agencies.
A resident with severe cognitive impairment and multiple medical conditions had a missing wallet, bank card, and cash, and the resident’s son reported unexplained recurring financial charges. The son informed Social Services of these concerns, and Social Services contacted the Business Office and discussed the issue with the interdisciplinary team, while the son planned to cancel the card. Although APS was eventually contacted and the facility assisted with canceling the card, there was no documentation in progress notes or grievance logs of the initial allegation, and no evidence that the state agency or the Administrator were notified when the concern was first reported, contrary to facility policy requiring immediate reporting of suspected misappropriation to the Administrator and appropriate state agencies.
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