A facility failed to report an alleged mistreatment during a resident’s hair grooming to the State Agency within the required timeframe. The resident had dementia, depression, severe cognitive impairment, and was dependent on staff for grooming and hygiene. Records showed a matted area of hair was removed, leaving a reddened scalp, and staff later described the event as an abuse allegation that should have been reported.
Failure to Report Abuse Allegation Within Required Timeframe: A resident reported that a CNA was too rough during care and did not want the CNA back in the room. The facility’s abuse policy required reporting abuse allegations to the state agency within 2 hours, but the DON stated the allegation was known at 7:50 PM and the initial report was not submitted until 10:06 PM. The resident had multiple psychiatric, cognitive, pain, and musculoskeletal diagnoses, and a BIMS score of 13 indicated intact cognition.
A facility failed to timely report an abuse allegation to the state agency for a resident with dementia and severe cognitive impairment. Staff learned that the resident stated he/she had been raped, the charge nurse verified the statement, notified the PA-C and POA, and documented the event, but the report to the state agency was not made within the required 2-hour timeframe after the facility became aware of the allegation.
A resident with severe cognitive impairment and on Eliquis was observed with circular bruising on the upper arm after the family reported the bruising to the DON and said it resembled fingerprints. The facility did not report the alleged physical abuse to the State Agency within the required 2-hour timeframe, and the administrator acknowledged the initial report was sent after more than 2 hours had passed.
Failure to Timely Report Abuse Allegations: The facility did not ensure abuse allegations were reported to the state survey agency within the required 2-hour timeframe. Incidents involved a resident with a history of aggression and poor impulse control who pulled another resident by the arm, slapped one resident, snatched a bingo card and used a vulgar slur toward another resident, and hit a fourth resident on the shoulder. Staff reported some incidents to the ADM or DON, but one was not reported at all before survey, one was reported the next day, and another was not submitted until days later.
Failure to Report Alleged Physical Abuse: A resident alleged that two CNAs were rough while repositioning them in bed and that the resident’s head was bumped into the headboard, causing pain. One CNA confirmed the head bump occurred during care, and the administrator stated the abuse allegation and failure to report were substantiated because the staff did not report the incident immediately.
Failure to Timely Report Allegation of Abuse: The facility failed to report an allegation of abuse for a resident with chronic pain syndrome, rheumatoid arthritis, major depressive disorder, and moderate cognitive impairment within the required 2-hour timeframe. The DON stated the ADON completed the investigation but did not timely notify OSDH, and there was no documentation that APS or the Nurse Aide Registry was notified at the time of the initial report.
Delayed Reporting of Abuse Allegation: A resident with moderate cognitive impairment and a history of bone cancer reported that a CNA was rough during incontinence care. The hospice nurse informed facility leadership, but the allegation was not reported to the state survey agency within the required 2-hour timeframe; the DON and Administrator acknowledged the delay.
Failure to Timely Report Suspected Abuse: A CNA did not immediately report a suspected abuse allegation involving a resident with Alzheimer’s disease, anxiety, and major depressive disorder. Instead of notifying an on-duty supervisor or the Abuse Coordinator, the CNA texted the off-duty ADON, and the allegation was not reported to the SSA within the required timeframe. Staff interviews confirmed the Abuse Coordinator was not notified immediately, and the DON and Administrator acknowledged the delay.
Failure to Report Allegation of Physical Abuse: A resident with severe cognitive impairment and Alzheimer's dementia was involved in an altercation with another resident after trying to take the other resident's food tray. The resident grabbed and clawed the other resident's arm, causing a skin tear with moderate bleeding, and both residents attempted to hit each other before staff separated them. The DON later stated the incident had not been known but should have been reported.
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