Failure to timely report an allegation of abuse involving a cognitively intact resident. The resident reported that an LPN removed medications from the walker basket after the resident said not to, and the resident also reported the LPN hit the resident’s hands, causing bruising and pain. The DON confirmed the incident and the Administrator confirmed the allegation was not reported to the State Agency as required by policy.
Failure to report allegations of misappropriation: A resident with major depressive disorder and anxiety disorder, and intact cognition per BIMS, alleged that an LPN was wearing and had stolen the resident's necklace, and later reported that another resident stole a phone charger. The SSD confirmed both events were allegations of potential misappropriation that required reporting to the State Agency, but the facility had no evidence that either allegation was reported.
A facility failed to report suspected neglect involving a resident with CKD stage 4, chronic lung disease, cognitive impairment, and DNR status after ordered BMP testing was not completed and 1 liter of LR was not given as scheduled. The missed lab and IV fluid were later identified, the BMP showed a critical high creatinine, and the resident was transferred to the ER, but the facility did not report the potential abuse/neglect, investigation, and findings to the State Agency as required.
Failure to timely report significant injury: A resident was found on the floor and later diagnosed with a distal fibula and medial malleolus fracture with minimal displacement. The report to APS was not made within the required 2 hours, and the Administrator confirmed the delay. Facility policy required serious bodily injury to be reported immediately, but no later than 2 hours after suspicion formed.
Failure to timely report abuse, injury, and theft allegations: the facility did not report a suspected abuse incident involving a resident, a fall with injury requiring ED care and sutures, and an unauthorized check cashing within required timeframes, and it did not submit written investigative reports to the state agency. The DON and Social Worker confirmed the missing state reports, and the abuse policy required reporting within 2 hours for abuse or serious bodily injury and written investigation submission within 5 working days.
The facility failed to submit an investigation to the State Agency within the required timeframe after an altercation between two residents. One resident had anoxic brain damage and schizoaffective disorder with a BIMS of 9, and the other had cerebral infarction, unspecified dementia, and generalized anxiety disorder with a BIMS of 12; both used wheelchairs. APS was notified, but the completed investigation was not submitted to DHHS until 9 working days after the event, and the Admin could not produce earlier grievance/complaint logs during survey.
Failure to Report Potential Neglect After Resident Fall: A resident who required a Hoyer lift and 2-person assist for transfers fell when a mechanical lift tilted during a transfer. An NA, MA, and LPN returned to the room, but the LPN only asked about pain and did not complete a post-fall assessment; there was no documentation of a post-fall evaluation in the EHR. The DON confirmed the event and stated the LPN’s failure to complete the evaluation was potential neglect that should have been reported to facility management and the State Survey Agency.
Failure to report allegations of abuse and neglect: two residents had grievances involving staff conduct, including delayed toileting assistance, humiliation, yelling, and profanity. One resident had a hx of stroke, incontinence, and dependence on staff for transfers/toileting hygiene; the other was cognitively intact with dx of dementia, anxiety, and depression. The facility confirmed the incidents and addressed them internally, but did not report the potential abuse/neglect concerns to the State Agency or APS.
The facility failed to report an allegation of physical abuse to law enforcement as required by its abuse reporting policy. A cognitively intact resident with dementia, anxiety, bipolar disorder, and major depressive disorder reported refusing a shower when a NA placed a lift sling under them, after which the situation escalated and both the resident and the NA exchanged punches. Skin assessments documented multiple new bruises on both of the resident’s arms and hands that were not present the prior day. Although facility policy required timely notification of law enforcement for such allegations, documentation in the abuse report form and EHR showed no law enforcement notification, and facility leadership confirmed that the incident and bruising were not reported to police.
A facility failed to submit a thorough investigation to the state agency after a resident experienced an unwitnessed fall while attempting a self-transfer, later being found to have a left femoral neck fracture, low Hgb, low BP, and pneumonia. The resident had multiple diagnoses, including dementia, COPD, ataxic gait, osteoarthritis, and weakness, was care-planned for wheelchair use at all times, and had a history of multiple falls and recent illness with fever and low O2 saturation. Although the DON identified weakness and low Hgb as possible causes of the fall, the investigation report submitted by the ADM did not include weakness as a cause and omitted key information such as the resident’s diagnoses, documented symptoms, BP findings, and whether medications had been reviewed.
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