Failure to timely report alleged abuse and neglect: A resident’s fall with injury was later found to involve a femur fracture, but the incident was not reported within the required 24-hour window. In a separate event, a resident reported verbal abuse by an agency CNA, and the DON acknowledged the allegation was not reported to the state agency within the required 2 hours.
Failure to Report Allegation of Neglect: A resident with ALS and hospice services alleged inadequate care and stated he felt unsafe after a CNA left him alone and closed his room door against his wishes. The Administrator and DON were notified, and the hospice administrator said the concern needed to be reported to state officials, but no SIMS report was submitted to the State Survey Agency.
Failure to timely report alleged staff-to-resident physical abuse. A resident’s wife alleged that staff physically abused the resident during a staffing meeting with staff and family present, and the ADON notified the Admin and DON by phone and began the investigation. However, the allegation was not entered into SIMS immediately upon discovery or within 2 hours as required.
Failure to Report Injury of Unknown Origin: A resident who was non-verbal and later transferred to the hospital for arm swelling was found to have bruising and swelling of the RUE with no observed cause. The DON could not determine the source after an investigation and staff interviews, and the injury was not reported to State Agency within the required 24 hours.
Failure to Report Allegation of Verbal Abuse: A cognitively intact resident reported that a CNA shut her in her room, stood very close to her, and cursed at her using degrading names. A CNA later confirmed the resident described yelling and cussing as verbal abuse, but did not report it because she thought it had already been reported. The DON and ADM stated they never received the allegation, despite policy requiring abuse allegations to be reported immediately, and no later than 2 hours if abuse is involved.
A resident with moderate cognitive impairment developed new pain and was found to have an acute, mildly displaced fracture of the right superior pubic ramus. Staff could not determine how the injury occurred, and the ADM did not file the required SIMS report within 2 hours after becoming aware of the injury.
Failure to Report Resident-to-Resident Physical Abuse: A resident-to-resident physical abuse incident was not reported to the State agency within the required 2-hour timeframe. An LPN witnessed one resident push another resident down, causing a facial bruise, and later saw the same resident push the other resident down again and drag her by the hair. The LPN did not document the second incident or complete an assessment, and the Administrator and DON acknowledged the incidents were not reported to the State agency.
Failure to report abuse allegations to the State Survey Agency: A resident was involved in a courtyard altercation where coffee was thrown and open-fist striking occurred, and two other residents were later involved in a separate fight where one resident was knocked from a wheelchair, pushed to the ground, and struck while staff intervened. The ADM stated he did not report the incidents because he did not consider one event abuse and did not know he needed to report the other.
Failure to timely report witnessed abuse: two residents were involved in a verbal and physical altercation after one resident used abusive language and the other slapped the resident. Multiple staff witnessed the incident, including an LPN and CNA, but the Administrator did not treat it as abuse because one resident had severe cognitive impairment and the incident was not reported to SIMS within the required 2-hour timeframe.
Staff failed to immediately report alleged abuse involving unauthorized physical restraints after finding two residents tied to their wheelchairs with sheets. A CNA admitted to restraining one resident, and an LPN and other CNA staff saw the second resident restrained but did not promptly notify the DON or Administrator as required by policy. Both residents had severe cognitive impairment and significant dementia-related diagnoses.
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