Late Reporting of Facility-Reported Incidents and Investigations: The facility did not report two incident allegations to the State Survey Agency within the required timeframe and did not submit investigation results within five working days for multiple incidents involving residents. The late reports included allegations of neglect, verbal abuse, staff-to-resident abuse, resident-to-resident verbal abuse, unauthorized Narcan administration, and CPR initiated when a POLST was not readily available. Staff member A stated she was responsible for the reports and acknowledged several findings were submitted late.
Late Reporting of Resident Abuse Allegation: The facility failed to timely submit the final abuse report after a physical altercation between two residents was identified. Staff said the incident was investigated and the report was completed, but it required review and approval by corporate regional staff before submission, and the final report was sent late.
Late Reporting of Possible Neglect: The facility failed to timely report an allegation of possible neglect involving a resident who fell during an assisted transfer when staff did not use the required gait belt and left the resident without continuous support. The resident developed increased back pain, was sent to the ED for evaluation, later transitioned to comfort-focused care, and died. The incident was known to the facility but was not submitted through the reporting system until several days later because an employee saved the report instead of submitting it.
Failure to timely report allegations of resident abuse: staff did not report two resident-to-resident abuse incidents to the State Survey Agency within the required timeframe. One resident was inappropriately touched by another resident, and in another event a resident was found in another resident’s room rubbing the resident’s leg; staff said the incident was not effectively communicated to the nurse, and the nurse thought the interaction was consoling rather than abusive.
A facility failed to timely report a resident incident to the State Survey Agency after a van driver slammed on the brakes, causing a resident to fall out of a wheelchair and onto the van floor. Staff said they were not informed until several days later, and the incident was then reported to the State Survey Agency.
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.
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