A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with ataxia fell from a facility van when the rear door opened during transport, after the transport driver failed to properly secure the resident. The driver did not immediately notify the DON or administrator, despite facility policy requiring all incidents and accidents to be reported at once. The DON learned of the event later and informed the administrator, who was responsible for reporting alleged neglect to the state agency within 24 hours. The administrator initially did not consider the event neglect and did not report it, although she later acknowledged that the failure to secure the resident in the van, resulting in the fall, met the facility’s definition of neglect and should have been reported within the required timeframe.
A resident reported that another resident entered her bathroom, shoved a door into her, pushed her against a wall causing her to fall, got on top of her, pulled her hair, and called her a derogatory name before staff intervened. The resident stated she informed an LPN of the physical and verbal abuse, but there was no documentation of the incident in her record and no internal incident or abuse report was initiated. The LPN and the RN weekend supervisor, both trained in abuse reporting, chose not to report the allegation to administration or complete required documentation because they did not witness the event and believed it did not require reporting, despite facility policy and definitions of abuse requiring that all such allegations be reported and investigated.
The facility failed to ensure that witnessed physical and verbal abuse of a resident by an LPN was reported to the administrator and state agency within the required 2-hour timeframe. An LPN repeatedly struck a resident’s face, head, and shoulders with a closed fist, placed her knee on the resident’s neck, attempted to drag the resident by his shirt, and yelled profanities at the resident in front of staff and another resident. The LPN also directed CNAs not to assist the resident from the floor or from his chair, and the CNAs left the unit for several minutes and later left the LPN unmonitored with access to all residents. Despite facility policies requiring immediate reporting of suspected or actual abuse, the CNAs who witnessed or were informed of the abuse did not notify administrative staff until the following day, and the administrator acknowledged the incident was not reported to the state agency within the mandated timeframe.
Failure to report a resident-on-resident abuse allegation to the State Survey Agency. A cognitively intact resident reported that another resident with severe cognitive impairment hit them with a cane, causing a skin tear and bruising. Nursing documentation described the altercation and the injuries, but the DON and Administrator confirmed the allegation was not reported to the State Survey Agency, despite the facility policy requiring timely reporting of suspected or identified abuse.
Failure to report an injury of unknown origin: staff identified an x-ray showing a fracture to a resident’s right hand, but the facility could not determine how the injury occurred and did not report it to the State Survey Agency within the required timeframe. The resident had cognitive impairment and was rarely or never understood, and the DON/ADM confirmed the origin of the injury remained unknown.
The facility failed to follow its abuse and injury reporting policy by not immediately informing the Administrator of an unwitnessed fall that resulted in serious bodily injury. A resident with multiple medical conditions, intact cognition, and no recent falls was found by an LPN lying face down on the floor, unresponsive, with a hematoma and laceration to the head and blood on the floor, and was sent to the ER where the resident later died. The DON was notified around shift change and then contacted the Corporate Administrator later that morning, but only reported that the resident had a fall, omitting that it was unwitnessed and involved serious head trauma, contrary to the requirement to report such events within two hours with full details.
The facility failed to report an injury of unknown origin with serious bodily injury to the State Survey Agency as required by its abuse reporting policy and state law. A cognitively impaired resident with multiple diagnoses, including dementia and a history of repeated falls, was found with bruising and swelling to the lower leg and later diagnosed by x-ray with acute fractures of the tibia and fibula. The resident could not explain the cause of the injury, and the facility’s investigation did not identify a cause, meeting the policy’s definition of an injury of unknown origin. Despite this, the Administrator, who was responsible for such notifications, did not report the incident to the State Survey Agency.
Failure to Timely Report Abuse Allegation: The facility did not report an abuse allegation to the State Survey Agency within the required timeframe after an incident in which one resident yelled, cursed, stood over another resident, and hit the resident on the lips. Both residents were moderately cognitively impaired, and staff interviews confirmed the behaviors met the definitions of verbal and physical abuse. The DON and ADM acknowledged responsibility for reporting, but the ADM stated the incident was not reportable because the resident had no injuries.
A facility failed to report resident-to-resident physical abuse to the State Survey Agency within the required timeframe. Two residents were involved in repeated altercations in which one resident struck the other and was later kicked in retaliation; the ADM was notified at the time of each incident, but the incidents were not reported to the state agency. One resident had dementia with behavioral disturbances and moderate cognitive impairment, while the other had bipolar disorder and depression with psychotic features.
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