A resident with moderate cognitive impairment, a history of falls, and transfer orders for a Hoyer lift only was moved by staff using a stand-pivot approach when she urgently needed the toilet. During the transfer back to bed, her legs gave out and she was lowered to the floor, then later found to have new left fibula and ankle fractures. The CNA told an LPN about the incident, but it was not documented or reported to management at the time, and the NHA later stated the event was not reported to the State Agency when she learned the resident had fallen after being transferred incorrectly.
Failure to Immediately Report Verbal Abuse: A CNA used profanity and disrespectful language toward a resident during care, and another CNA witnessed the abuse but did not report it immediately to the Abuse Prevention Coordinator. The DON confirmed staff delayed reporting for several days and also knew the CNA had been abusive to other residents previously, but those incidents were not reported.
Failure to Report Alleged Verbal Abuse: The facility did not report an allegation of verbal abuse involving a resident to the state agency after a staff member was accused of making degrading comments while the resident needed care. The resident had depression, anxiety disorder, bipolar disorder, intact cognition with a 15/15 BIMS, and required substantial to maximal assistance with toileting and bathing, plus dependence for lower body dressing and transfers. The Administrator and DON said the allegation was not reported because the investigation did not substantiate it, despite the facility’s documented knowledge of the allegation.
Failure to Report Substantiated Verbal Abuse: The facility did not report a witnessed verbal abuse incident by a CNA to the State Agency or the Nurse Aide Registry, and did not report the investigation results for a resident involved. A housekeeper overheard the CNA use abusive language toward a resident with dementia and severely impaired cognition, and the administrator later confirmed the event was substantiated, but it was not reported as required by the facility abuse policy.
The facility failed to timely report suspected neglect involving unadministered resident medications on two occasions. Staff found a pharmacy bag of medications with trash at the nurses’ station and later found another bag of unadministered medications in a dumpster, with concerns that the DON had charted meds as given before actually administering them. Multiple LPNs reported prior similar incidents and said residents had complained of missed meds, but the incidents were not reported to the State Agency within the required timeframe.
Failure to Report and Investigate Allegations of Abuse and Theft: A resident with severe cognitive impairment alleged that a CNA kissed him, and staff acknowledged awareness of the allegation, but it was not reported or investigated. In a separate incident, one resident punched another resident after the injured resident had accused him of stealing clothing; the NHA later admitted the theft allegation was not reported to the state agency and the investigation was not documented.
Failure to Timely Report Abuse Allegations: The facility did not timely report two abuse allegations to the State Agency within the required two-hour timeframe. One incident involved two residents after a CNA heard loud voices and a smack sound, with one resident alleging he was slapped after a racial slur was used; the other involved a resident with Alzheimer’s disease entering another resident’s room and striking her with a hand and comb. The NHA acknowledged both reports were late.
Failure to report an injury of unknown origin: A resident with MS, severe malnutrition, dementia, impaired cognition, and total dependence for bed mobility and transfers developed a proximal femur fracture after reporting pain. The NHA stated the facility could not determine how the fracture occurred, the resident denied abuse, and the injury was not reported to the State Agency because staff did not believe it was abuse or an allegation of abuse.
Failure to Timely Report Allegation of Abuse: A CNA documented that one resident with severe cognitive impairment inappropriately touched another resident who was also severely cognitively impaired and wheelchair dependent. The incident was identified in the EMR as an allegation of abuse, but it was not reported to the Abuse Coordinator per facility policy, and the initial report to the SA was not timely.
Failure to Report Injury of Unknown Origin: A resident with severe cognitive impairment, aphasia, Alzheimer’s disease, dementia with agitation, and wandering behaviors was found with unexplained bruising and swelling to the right arm/elbow. The injury was documented as unwitnessed and the resident could not describe what happened, yet the facility did not report it to the State Agency because the DON/Administrator believed the cause had been determined. The incident report lacked a documented investigation explaining the injury.
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