Failure to Report Allegation of Neglect Involving Improper Hoyer Lift Transfer: A resident with dementia, stroke, and ESRD who was fully dependent for transfers slipped out of a Hoyer lift during a transfer and sustained a head injury. The incident was reported to the State as a fall with injury, but the DON knew the CNA used the wrong sling for the wrong lift and did not have a second staff member present, and the report did not identify the event as an allegation of neglect.
Failure to Report Injury of Unknown Origin: A resident had multiple skin tears, bruises, discolorations, and redness documented on admission and again on a later skin assessment, including bruising to the face, chest, extremities, abdomen, and feet. An LPN stated new skin areas should trigger documentation, risk management, treatment, and notification of management, but the ADON confirmed no internal risk management report was initiated, and the facility lacked evidence that the injury of unknown origin was reported to the State Agency.
Failure to report resident abuse, sexual misconduct, and injuries of unknown origin: Staff documented multiple resident-to-resident physical abuse incidents involving a resident with dementia and repeated sexual inappropriate behaviors by another resident, but the incidents were not reported to the Administrator or reflected on the reportable log. Staff interviews showed some events were observed but not escalated. The facility also documented bruises and other injuries of unknown origin for a severely cognitively impaired resident, but the Administrator confirmed the injuries were not reported to the SSA.
A resident with spastic quadriplegic cerebral palsy had diazepam, a Schedule IV controlled substance, sent with a guardian during LOA. When the resident returned, the guardian refused to return 2 unused doses and kept them in her personal bag. Staff documented the missing medication and notified administrative staff, but interviews confirmed law enforcement was not contacted when the controlled medication was not returned.
Failure to timely report injuries, abuse, and neglect: A dependent resident with severe cognitive impairment and total transfer dependence was found with a hematoma and bruising to the forehead/eye area, but the injury was not reported to the State Survey Agency for more than 26 hours. Multiple CNAs, an AA, and an LPN observed the injury during care and rounds, yet the findings were not consistently escalated or documented. The facility also delayed reporting alleged neglect and other resident allegations, including missed care and a staff member not returning to provide care for the rest of a shift.
Failure to timely report an injury of unknown source: A resident with a fractured right hip had a facility incident documented after an x-ray showed the injury, but the report was not submitted to the State Agency within the required timeframe. The DON confirmed the late reporting during interview.
A resident reported an allegation of physical abuse by a CNA during the night shift, which was documented in the clinical record. Facility policy required that all alleged violations be reported to the Administrator, state agency, APS, and other required agencies immediately but no later than two hours after the allegation. Instead, the allegation was reported to the state agency approximately nine hours after it was made. An RN acknowledged not reporting the allegation right away and waiting for the day shift, and the DON confirmed that the reporting timeframe was not followed.
A cognitively intact resident with mild cognitive impairment reported to her son that a male CNA entered her room at night to provide incontinent care, which she refused, and that he returned and made an inappropriate sexualized remark when she again refused care. The son called the facility to report the concern, and the Admissions Director stated she immediately informed the DON, in line with protocol to notify leadership of abuse-related grievances. However, the DON reported she did not recall receiving the grievance and only became aware of the allegation when law enforcement arrived several days later after receiving a family complaint. The DON confirmed that the SSA was not notified of the abuse allegation until four days after the initial grievance, despite facility policy and leadership acknowledging that alleged abuse must be reported to the SSA within two hours.
Failure to timely report allegation of verbal abuse. A resident reported that an RN used expletive language during an encounter after the resident returned from going outside to smoke, and the RN told the resident the resident was not allowed to go outside and that staff would not buzz the resident back in. The facility initially handled the matter as a grievance and did not report it to the State Survey Agency within the required 2-hour timeframe.
A resident with dementia, severe cognitive impairment, and a history of multiple falls was noted by a PTA to have increased edema on the right forearm during therapy, and later the same morning an LPN documented a hematoma, pain, and notification of the NP, who assessed right arm swelling with preserved range of motion and circulation. The resident was unable to explain the cause of the injury due to cognitive impairment, making it an injury of unknown origin. The Administrator and DON stated they determined whether such incidents needed to be reported and confirmed this event was not reported to the state, despite a facility policy requiring all alleged incidents, including injuries of unknown source, to be reported to the Administrator or designee and then to appropriate regulatory agencies and/or law enforcement.
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