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 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.
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.
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