A resident with COPD, diabetes, and heart failure on continuous O2 was reported to have a visitor in the late afternoon, but an RN did not check on the resident for several hours and later could not locate the resident for medication administration. The resident was subsequently found on the floor unresponsive, with no pulse or respirations, and was pronounced deceased by EMS. Documentation showed no record that the resident was missing for several hours, no notification of the nursing supervisor or MD, and no documentation of dinner, hourly safety checks, or medication administration during that time. An internal investigation concluded the event was a medical incident and found no cause to believe abuse, mistreatment, or neglect had occurred, and the allegation was not reported to the State agency, despite facility policy requiring timely reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment.
A resident with dementia, severe cognitive impairment, and mobility limitations was in a wheelchair in a day room when video footage showed a CNA striking the back of the resident’s head after the resident reached backward toward the CNA. An environmental services worker observed the CNA “pop” the resident on the head and informed an LPN at the time, but the LPN, influenced by knowledge of interpersonal conflict between the CNA and the worker, did not report the allegation. The worker did not escalate the concern until several days later, and the DON only became aware of the incident and confirmed it on video at that time, resulting in the abuse allegation being reported to external authorities well beyond required timeframes.
A resident with dementia, syncope, and gait abnormalities, assessed as severely cognitively impaired, was found on the hallway floor after staff heard an alarm, with an unwitnessed fall from a wheelchair and a laceration above the right eyebrow. Hospital records confirmed an acute C2 (odontoid) fracture and recommended neurosurgery follow-up, indicating a major injury of unknown origin. The facility’s incident report described the event as unwitnessed, with the resident confused and unable to follow instructions, while nursing staff were occupied in the med room and providing care to other residents. The facility’s abuse investigation policy addressed investigation of injuries of unknown source but lacked protocols for reporting them to the State Survey Agency, and leadership interviews revealed uncertainty and misunderstanding about the requirement to report such major injuries, resulting in the incident not being reported to the state health department.
A resident with morbid obesity, lymphedema, and GAD, who was care planned to require two staff for bed mobility, slipped from the bed to the floor when a CNA provided incontinence care alone and turned the resident onto their side. The facility’s incident report documented no injury and full ROM, but the event, an alleged neglect incident involving failure to follow the two-person assistance requirement, was not reported to the state health department within the required timeframe, and the DON later stated it was deemed non-reportable despite facility policy assigning responsibility to leadership to determine and complete required external reporting.
A resident with severe cognitive impairment and resistance to care was being assisted with hygiene after bowel incontinence when a CNA allegedly pushed the resident toward a sink, spoke sternly, and rushed care, with the resident saying “ouch.” The assisting CNA, who witnessed the incident, completed the shift and did not report the allegation to a supervisor or the Administrator until the following day, citing fear of backlash. This delay meant the allegation of verbal and physical abuse was not reported within the facility’s required two-hour timeframe, the resident was not promptly assessed, and the alleged perpetrator continued to have access to residents until the end of the shift.
The facility failed to report the results of an internal investigation of a resident-to-resident abuse incident to the State Survey Agency as required by policy and state regulations. During an acute psychotic and aggressive episode, a resident with vascular dementia, depression, and anxiety threw objects at staff, climbed into another resident’s bed while that resident was in it, and entered another resident’s room, where a tray table struggle occurred and a thrown chair struck the resident’s foot. An internal investigation was completed and skin assessments were performed, but the event was not reported to the state. In interviews, the DON stated they did not consider the incident reportable and believed the administrator was responsible for state reporting, while the administrator indicated the DON completed investigations.
A resident with a history of CVA, neuropathy, hemiplegia, moderately impaired cognition, and dependence for transfers was care planned for use of a full body lift with two staff. During a transfer using the lift, the resident fell and sustained a head laceration that required staples in the ED. The cause of the fall could not be determined, making it an injury of unknown source. Despite a facility policy requiring prompt reporting of alleged abuse, neglect, mistreatment, and injuries of unknown source to the State Survey Agency, including serious bodily injury within two hours, the DON did not report the incident because it was not considered reportable.
The facility failed to report an allegation of staff-to-resident abuse to the state as required by its abuse prohibition policy and regulations. A resident with Type II DM, bipolar disorder, COPD, and moderate cognitive impairment alleged that a CNA was physically rough, grabbing and pulling the resident’s arms during an argument about bathroom use, and the resident stated they felt they needed to call 911. The allegation was documented on a grievance form, but not in the resident’s progress notes, and there was no evidence it was reported to the NYSDOH within 24 hours. The Administrator acknowledged the event was an allegation of abuse that should have been reported but stated it was not reported due to the resident’s history of making false allegations.
A resident with severe cognitive impairment and diagnoses including CVA, seizure disorder, and Parkinson’s disease was found on the floor by an LPN with uncontrolled tremors, facial lacerations, and later-confirmed bilateral nasal bone and septal fractures after an unwitnessed fall. Facility documentation classified the event as a fall of unknown origin, and an RN supervisor completed an investigation concluding the resident likely rolled out of bed due to tremors, with no evidence of abuse or neglect. Despite a written policy requiring serious injuries of unknown or suspicious origin to be reported to the NYSDOH within specified time frames, the DON, ADON, and Administrator determined the incident was not reportable, and it was never reported to the state agency.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
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