Failure to report alleged sexual abuse within required timeframe. A resident with intact cognition and significant ADL dependence alleged that a CNA raped them during incontinence care; the resident later described possible penetration and burning, while the CNA said they only provided brief care and applied ointment. The family member contacted law enforcement and requested hospital transfer, but facility leadership did not report the allegation to DOH within 2 hours, stating they believed the allegation had changed to rough handling and did not meet the reporting threshold.
Failure to Immediately Report Alleged Abuse: A CNA witnessed another CNA strike a resident in the face but did not report the alleged abuse right away, waiting about two and a half hours before notifying the ADON. The resident had Alzheimer's disease, Lewy body neurocognitive disorder, atrial fibrillation, and severe cognitive impairment. Facility policy required immediate reporting of suspected abuse to a supervisor or administrative staff, and the DON stated the incident should have been reported immediately.
Failure to Timely Report Injury of Unknown Origin: A resident with dementia, osteoporosis, and severe cognitive impairment complained of hip pain while being repositioned, was later found with swelling and abnormal leg positioning, and was transferred to the hospital where a fracture was confirmed. The facility learned of the fracture from the hospital but did not notify the State Agency within the required 2-hour timeframe for an injury of unknown source.
Failure to report an abuse allegation within the required timeframe and failure to keep resident medications secured. A resident on a puree diet was given an egg salad sandwich by a CNA, began choking, and required the Heimlich maneuver after appearing cyanotic. In separate findings, two residents who were not approved for self-administration had medications at bedside, including Nystatin powder and an OTC sleep aid.
Failure to Timely Report Abuse Allegations: The facility did not timely report two abuse-related allegations to the State Survey Agency. One resident with severe cognitive impairment and ventilator dependence was found with a hand mitten tied to the bedrail, and another resident with CVA, hemiplegia, and diabetes had a family-reported allegation that a staff member struck the resident in the face. In both cases, the DON/Administrator were not notified in the required timeframe, and the reports were not submitted within the required 2-hour reporting window for abuse allegations.
The facility failed to report two investigated events to DOH: one resident with severe cognitive impairment had an unexplained forehead injury, and another resident with severe cognitive impairment was found on the floor with an acute hip fracture after an unwitnessed fall. In both cases, staff could not establish the cause of the injury, but the DON and Administrator determined the events did not meet reporting criteria and did not notify DOH.
Failure to Timely Report Alleged Abuse: A resident with dementia and severe cognitive impairment was the subject of an alleged staff-to-resident physical abuse incident when a housekeeper reported seeing a staff member push the resident and swear at them. The housekeeper delayed reporting because they were scared, and the DOR of Housekeeping did not notify the Administrator or DON right away, resulting in the allegation not being reported within the required 2-hour timeframe.
Failure to Timely Report Alleged Abuse: A resident who was cognitively intact and independent with decision making alleged that an aide was rough and pushed them into a wheelchair before they were ready. Staff and family described the incident, but the allegation was not documented as an abuse report, and the DON could not provide an investigation or confirm timely notification to the Administrator or state agency as required by policy.
Failure to report investigation results for suspected misappropriation: A resident with cellulitis, OA, and AFib had intact cognition when an agency contracted staff member allegedly took the resident’s driver’s license, SS card, and debit card and used the card for purchases. The facility notified DOH of the allegation, but there was no documented evidence that the investigation results or related documentation were submitted to the State Survey Agency within the required timeframe.
Failure to Timely Report Alleged Abuse and Injuries of Unknown Source: The facility did not report multiple alleged abuse or injury events to the State within the required 2-hour timeframe. One resident with dementia injured a hand after punching a window, another resident with dementia and a fall history said they were pushed after being found on the floor with a facial hematoma, and a third resident with severe cognitive impairment had an unexplained thigh bruise that was not reported. Staff interviews confirmed the reporting delays and omissions.
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