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.
Failure to Timely Report Allegation of Abuse: A CNA observed another CNA handling a resident roughly during transfer and speaking to two residents in a loud, dismissive, and profane manner. The concerns were not reported to the charge nurse right away, and the facility’s abuse report was not submitted to DIAL within the required 2 hours. The ADON confirmed the allegation should have been reported immediately.
Failure to timely report missing resident narcotics: A resident with chronic pain and multiple comorbidities had Hydrocodone-Acetaminophen ordered for PRN pain. Staff found discontinued opioid tablets still on the cart, placed them at the nurses’ station for destruction, and later discovered 54 tablets were missing. The DON and Administrator did not report the missing meds to police or the State Agency until days later, despite policy requiring immediate reporting of suspected misappropriation.
Failure to Report Staff Video of Resident Urinating: A CNA showed another CNA a video of a male resident urinating in a trash can in the chapel, and the video was also shared in a Snapchat group with other CNAs. The staff member who saw it did not report it because she believed the resident was fully dressed and did not think it was inappropriate, despite having abuse-reporting training. The DON later learned of the incident through another RN and interviewed the CNA, who admitted sending the video and gave changing accounts of what was shown.
Failure to report and investigate injuries of unknown origin: Two residents with significant cognitive impairment and anticoagulant use had unexplained bruising documented, including a wrist bruise and bruising under an eye with pain. The clinical record lacked documentation of an investigation and lacked evidence that DIAL was notified, despite the facility policy requiring immediate reporting of alleged abuse, neglect, and injuries of unknown origin to leadership.
Failure to report misappropriation of resident medication. An LPN/charge nurse self-administered a resident’s PRN Zofran after becoming ill while on duty, and another LPN reported seeing the medication taken. The Administrator confirmed the incident but did not report it to the state agency, stating it was not a controlled substance, despite facility policy requiring suspected misappropriation to be reported immediately.
Failure to Timely Report Resident-to-Resident Abuse: The facility did not report an allegation of resident-to-resident abuse to DIAL within the required 2 hours. A resident was found after a confrontation with his roommate, who was lying on the floor in a pool of blood with a 13 cm head laceration and was sent to the ER. The self-report was not documented as called in until the next day, and DIAL call logs did not show a call from the facility that evening.
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