Failure to Report Injury of Unknown Origin: A resident with Parkinson’s disease, dementia, and severe cognitive impairment developed swelling, blistering, and redness on the right hand, later treated in the ER as a second-degree burn. An LPN and CNA observed the injury, but the LPN did not report it because it did not appear to be a burn, and the DNS stated the injury of unknown origin should have been reported to the State Agency.
A resident with dementia with Lewy bodies, depression, hallucinations, and other diagnoses eloped from the facility and was found deceased three days later. The facility did not report the potential allegation of neglect to the State Agency in a timely manner, and the DNS stated she did not report it because she did not believe it was an elopement.
Delayed reporting of alleged verbal abuse occurred when a resident reported abuse to a CNA, who informed an LPN, but the allegation was not initiated until several days after the event. A CNA witnessed the incident but did not report it right away because she was agency staff and did not know who to notify. The Administrator stated the delay by staff caused late reporting to the State Agency.
Failure to Report Allegations of Verbal Abuse: The facility did not report multiple allegations of verbal abuse involving one resident toward several other residents to the State Survey Agency. Grievance forms and staff statements documented homophobic slurs, foul language, and threats of physical assault, while the Administrator stated she did not believe the allegations rose to the level of reportable abuse.
Failure to timely report an abuse allegation involving a resident with respiratory failure. The resident reported that two CNAs injured the resident's back while assisting with repositioning in bed, and a staff note documented the resident screaming in pain and stating staff caused the pain. Staff said the allegation was reported to the charge nurse and noted for the RCM, but the DON/Administrator were not immediately notified and the state was not reported within the required time frame.
A resident with respiratory failure and pneumonia, who was Full Code and not on hospice, was found during routine rounds and suspected to be deceased. Nursing staff assessed the resident, noted there was no rigor mortis, confirmed death, and did not initiate a code blue or any resuscitation efforts despite the resident’s Full Code status. The facility later treated this as a potential neglect incident but did not report it to the State Agency within the required two-hour timeframe, as confirmed by the regional QA director.
A resident with a hip fracture and anxiety reported to social services that a CNA had been rough, told the resident to take themself to the bathroom, and instructed them not to get out of bed until a specified early morning time. The allegation was received by facility staff in the late afternoon, but the incident report was not submitted to the State Agency until the following day, exceeding the required 2-hour reporting timeframe acknowledged by the DNS. The deficiency concerns this untimely reporting of an abuse allegation, despite the CNA’s denial of any abuse.
The facility failed to timely report two separate allegations of abuse and neglect to the State Agency. In one case, a resident with severe cognitive impairment and an anoxic brain injury developed significant swelling and bruising of the right knee, later confirmed as a fracture, which was known to staff but not promptly reported to administration or the State Agency. In another case, a resident with dementia and moderate cognitive impairment, dependent on toileting and personal hygiene, was allegedly left without incontinence care for an entire CNA shift, and this neglect allegation was not reported to the State Agency within the required two-hour timeframe. Leadership, including the DON and Administrator, acknowledged that both incidents were reported late.
The facility failed to timely report suspected resident-to-resident physical abuse to the proper authorities. Two residents, one with major depressive disorder and another with senile degeneration of the brain with anxiety and agitation, were involved in an altercation in which one resident struck the other with a reader stick after the other entered the room looking for personal items. A progress note documented that a resident reported being hit by another resident and was observed receiving a bandage to the knee. The Social Services Director completed an incident report and informed the administrator and DNS around midday, but the FRI was not submitted until several hours later, exceeding the required 2-hour reporting timeframe acknowledged by the DNS.
The facility failed to report allegations of abuse within the required 2-hour timeframe for three residents. The policy required suspected or alleged abuse to be reported immediately, but the FRI was not sent to the SA until later, and the DNS stated he was not aware of any other attempts to contact the SA within the required timeframe. The Administrator confirmed the report was submitted late.
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