A resident with altered mental status developed bilateral wrist discoloration and swelling during ADL care when a CNA reported the resident was resisting and bumped both wrists against a wheelchair during transfer. An RN completed an incident report and nursing note documenting the injury, assessment, and physician notification with an order for x-ray. Facility leadership later acknowledged that this event, which met their policy criteria for an allegation requiring reporting within two hours if involving abuse or serious bodily injury, was not reported to the state survey agency, contrary to the facility’s written abuse, neglect, and exploitation policy.
Facility staff failed to timely report an allegation of abuse involving a resident with moderately impaired cognition and a diagnosis including malignant neoplasm of the colon. The resident reported being shoved back into bed by staff after nearly falling, and a facility synopsis documented that she was shoved twice by two staff members while being assisted to bed. The incident date and the report date in facility records showed a five-day delay before the allegation was reported to state agencies. Staff interviewed during the survey stated they were not aware of the incident, and leadership provided no additional information about the delay, resulting in a deficiency for failure to promptly report suspected abuse.
The facility failed to follow its abuse policy by not timely submitting the final 5‑day investigative summary of an altercation between two residents to the state survey agency and by not notifying the involved resident’s representative of the investigation outcome. After a resident reported being struck in the eye by another resident during a struggle over a reacher/grabber tool, staff separated the residents, documented bruising and swelling to the injured resident’s eye, and initiated required assessments and notifications. The initial incident report was faxed to required agencies, and the final 5‑day summary was successfully sent to adult protective services and the ombudsman, but multiple fax attempts to the state survey agency failed, with no documented re‑attempts on subsequent business days as required by policy. The injured resident was later transferred to the ED and did not return, and there was no documentation that the resident or the resident’s representative was informed of the investigation’s outcome.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
Failure to Timely Report Allegations of Abuse: The facility did not have credible evidence that allegations of abuse involving three residents were reported to APS and the state survey agency within required timeframes. One resident struck another with a rock, another resident was assaulted during a courtyard altercation and required pain medication, and a third resident was involved in a physical altercation with a staff member and another resident, with minor scratches noted. Facility interviews stated abuse reports should be made within 2 hours, with final reports later submitted, but the records did not show timely regulatory reporting for these incidents.
Failure to Timely Report Resident-to-Resident Abuse Allegations: The facility did not ensure allegations of resident-to-resident abuse were reported to the SA within required time frames. One resident with intact cognition was documented as being struck by a roommate, and another resident with intact cognition was threatened and yelled at by a peer, leaving the resident uncomfortable and fearful. An LPN and the Administrator gave conflicting accounts of reporting, and the Administrator stated she was not aware of the regulatory requirement for immediate reporting of abuse or serious bodily injury allegations.
A resident with dementia and weakness was found lying on the floor with right leg pain after an unwitnessed incident and was emergently transferred to the hospital. Facility documentation showed the resident was not interviewed about the event, and leadership later confirmed that the former Administrator did not report this injury of unknown origin to the State Survey Agency as required. Review of facility policy showed that all injuries of unknown source, including those involving possible abuse or serious bodily injury, must be reported immediately, but not later than two hours after the allegation is made.
A resident with severe cognitive impairment and behavioral disturbances became combative during care with a CNA, resulting in a skin tear to the resident’s finger and a bruise under the eye. The resident later stated to an RN that the CNA had punched her. The RN reported the incident and allegation to an LPN, who said the DON would be notified but did not contact the DON that night. The DON only learned of the allegation the next morning, and the SSA was not notified until later that day, contrary to facility policy requiring immediate reporting and notification within two hours for abuse allegations.
Facility staff failed to investigate an allegation of abuse after a resident with paraplegia and depression, who was cognitively independent, was reported by another resident to have pulled a knife and made him fear for his life. Nursing staff notified the DON, contacted 911, and attempted to search the resident’s belongings, but the resident refused a full search and left the unit. Despite the Administrator’s stated procedure and facility policy requiring prompt initiation of an investigation and reporting of all abuse allegations, no incident report or investigation was completed or documented for this event.
Failure to Report Allegations of Abuse and Missing Property: A resident with intact cognition reported verbal abuse by a CNA after refusing a late shower, but the allegation was not reported to the state agency within the required timeframe. Another resident with moderately impaired cognition reported missing personal and identification cards, yet staff did not timely escalate the allegation to administration or state agencies as required by policy.
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