Late Reporting of Abuse Allegation: The facility failed to report an allegation of resident abuse within the required timeframe. An abuse allegation involving a resident and NF1 was verbally reported to a new staff member, who stated she was not aware of the 24-hour reporting requirement. The incident was later submitted to the State Survey Agency, and another staff member acknowledged the allegation was reported late. The facility policy required abuse to be reported no later than 24 hours after the allegation is made to the DON or designee and other officials.
Late Reporting of Suspected Abuse and Injury of Unknown Origin: The facility failed to timely report two reportable events involving suspected abuse or injury of unknown origin. One resident was found on the floor and later diagnosed with a periprosthetic hip fracture, but the allegation was not reported to the State Survey Agency until 2 days later. Another resident was physically assaulted by a male resident, but the incident was not submitted through the reporting portal until 56 days later. Staff said the facility had a reporting process, but they were unsure where the breakdown occurred.
Untimely submission of investigative findings for a resident fall incident. A CNA found a resident walking back to bed from the bathroom in socks with a cane after the resident said she had fallen and was favoring her L leg with pain. The facility later determined the resident had an acute L-sided pubic rami fracture, but the investigative findings were not sent to the State Survey Agency within the required timeframe. Staff said the delay was due to not realizing the report had not been submitted, and the facility policy did not include a procedure or timeframe for submission.
Failure to Timely Report Reportable Incidents: The facility did not submit multiple reportable incidents to the State Survey Agency within the required 24-hour timeframe. Incidents included resident-to-resident verbal altercations and aggressive behavior, such as derogatory statements, threats, and throwing cups at staff. An LPN/staff member stated she was the only person who knew how to use the online reporting portal, so incidents that occurred on weekends or holidays could be reported late.
The facility failed to submit required investigation findings to the State Survey Agency (SSA) within 5 working days for multiple abuse and elopement incidents. In one case, a resident kicked another resident’s feet, and in another, one resident kicked another in the legs while both were in wheelchairs; in both situations, the facility did not provide timely or, in one case, any investigative findings to the SSA. The facility also reported two separate elopement events for a resident but did not submit final investigation reports for either incident. A staff member reported that another staff member, who was absent during the survey, was responsible for SSA reporting, and confirmed the expectation to report all investigation results within 5 working days per facility policy.
The facility failed to timely report several allegations of abuse and neglect to the administrator and State Survey Agency as required by its policy. In one case, a resident experienced inadequate hygiene care and lack of monitoring after vomiting, identified later on video, but the allegation was not promptly reported. In another incident, a staff member’s physical contact caused a resident to lose balance and be assisted to the floor, and both the involved staff and a witness delayed notifying the nurse. In a third situation, a staff member allegedly verbally abused two residents by threatening a cold shower and ordering a resident to sit down and be quiet, and the witnessing staff member did not report these events until days later, resulting in late external reporting.
Two residents were involved in an altercation over a weekend, and the nurse on duty did not promptly notify the DON or Administrator, resulting in the incident not being recognized by leadership until a chart review was conducted later. An attempt to submit the initial abuse allegation report to the State Survey Agency was made but not successfully saved in the reporting system, and no immediate resubmission occurred. The full investigation, including the initial report, was submitted several days later, causing the initial abuse report to be filed late, despite staff having received prior abuse reporting training.
A resident reported that a former staff member repeatedly left the call light unanswered for extended periods, did not provide needed ADL assistance, and encouraged the resident to sign refusal-of-care forms, resulting in the resident soiling briefs before being asked to ambulate to the restroom. Another staff member stated that no care concerns had been brought to their attention and acknowledged that the alleged abuse and neglect were not reported. When surveyors requested IDT notes, root cause analysis, reporting, and investigation documents related to the staff member and this resident, the facility was unable to provide any documentation, indicating the allegation was not timely reported to the State Survey Agency or investigated.
Failure to Report Alleged Neglect Involving Dislodged Nephrostomy Tube A resident with a nephrostomy tube reported that a CNA pulled the tube out during care, and the tube was later found displaced with no urine output. Staff knew about the allegation, but one staff member did not report it to the administrator, and the facility did not submit the incident to the State Survey Agency because the IDT did not view it as neglect. The NHA later spoke with the resident about the incident, but that conversation occurred after the allegation.
The facility failed to timely report an allegation of sexual abuse and to submit investigation findings for multiple abuse-related events to the State Survey Agency. A resident with a history of inappropriate contact with female residents was observed placing his hand on another resident's thigh while assisting with feeding; a staff member intervened and reported this to a nurse, who documented the behavior but did not report it as required. In separate incidents, a verbal altercation between two residents and a resident's allegation of verbal abuse by a staff member were reported as events, but the required investigation findings were submitted to the state one day past the regulatory deadline, despite internal alerts and established abuse-reporting policies.
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