Failure to Timely Report Abuse and Theft Allegations Staff did not report two residents’ allegations of mistreatment and misappropriation to DIAL within the required 2 hours. One resident with severe cognitive impairment and incontinence was overheard being told to urinate in her brief while staff were busy with another transfer, and another resident with intact cognition alleged a CNA stole coins from her drawer and retaliated against her with wheelchair contact. Staff interviews showed the allegations were discussed internally, but the required external reporting timeframe was not met.
Failure to timely report an unwitnessed resident death with positional findings: the facility did not notify the State Agency within the required 2-hour timeframe after forming suspicion that the event involved an injury of unknown origin with serious bodily harm. The former Administrator and DON stated they believed the resident died of natural causes and deferred reporting while awaiting further information, and the incident was later submitted as a late self-report after QAPI review and legal involvement.
Failure to report allegations of abuse and financial exploitation: A resident with Alzheimer’s disease and moderate cognitive impairment had concerns raised by a family member about fraudulent bank activity, POA misuse, and medical decision-making by the former Administrator, who was also the resident’s ex-stepdaughter. APS and facility leaders were informed, but staff did not treat the concerns as reportable allegations and instead documented them and kept an eye on the situation rather than reporting to DIAL as required by policy.
Failure to Report Alleged Sexual Abuse Between Two Cognitively Impaired Residents: Two residents with impaired cognition and sexually inappropriate behaviors progressed from kissing and holding hands to fondling and touching without clothing. The DON and Administrator treated the relationship as consensual based on apparent enjoyment and body language, did not obtain capacity evaluations, and did not report the incident as abuse even though facility policy defined sexual contact with a resident lacking the cognitive ability to consent as non-consensual and required immediate reporting.
Failure to Timely Report Suspected Abuse and Neglect: An LPN reported questionable actions toward a resident with severe cognitive impairment and diagnoses of cancer and non-Alzheimer's dementia, including removal of room identifiers, unplugging the resident's phone, and not allowing the resident to go to bed when asked. The DON and administrator received the report, but the allegation was not submitted to the state agency within the required timeframe, and staff stated they did not believe the resident was being mistreated.
Failure to Report Alleged Abuse: Staff members described a Dietary Aide using profane and derogatory language toward a resident with intact cognition after becoming upset over a meal issue, but the incident was not reported to the State Agency or the Administrator. Multiple staff heard about the exchange, yet each believed someone else would report it, and the facility had no incident report on file for the allegation despite policy requiring timely reporting of alleged abuse.
Failure to timely report abuse allegations: Staff documented an incident in which a CNA/CMA used physical force during a shower with a combative resident, and leadership did not notify DIAL or law enforcement when the allegation was first reported. A separate allegation involved a resident on the dementia unit who reportedly punched a CNA/CMA, after which the CNA/CMA grabbed the resident’s arm; that incident was also not reported to DIAL or law enforcement. Facility interviews showed leadership debated whether the events were abuse and delayed reporting despite policy requiring immediate notification.
Failure to Timely Report Allegation of Abuse: The facility did not timely submit a self-report for an allegation involving a resident with intact cognition, recent surgery, wound care needs, HF, DM, and a hip fracture. A representative alleged negligent care and reported that wraps were left on overnight, were too tight, and caused bruising and blisters; the DON also documented provider follow-up and the daughter’s concern about the resident’s foot. The facility later recognized that a self-report should have been filed for the allegation, but it was submitted late instead of immediately as required by policy.
Failure to Timely Report Allegation of Abuse: A resident with intellectual disability, stroke, and hemiplegia was found naked and rolled onto her side in bed while a CNA left the room, then was aggressively brushed despite braids still being in her hair, causing pain and crying. Another CNA reported the concern to an LPN and said she knew there was a 2-hour reporting requirement, but the LPN did not report it. The ADON and DON were not notified until later, and the state report was filed after the required timeframe.
A facility failed to timely report two abuse-related events to DIAL: one resident with intact cognition developed an unexplained rib fracture after worsening pain and ER evaluation, and another cognitively intact resident had bruising to the wrist and elbow after stating staff grabbed him too hard during care. The records showed internal documentation and resident statements, but no timely abuse/unknown-origin reporting to the state agency.
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