The facility failed to demonstrate that an allegation of physical abuse between two residents was reported to authorities within the required two-hour timeframe. A resident was punched in the shoulder by a co-resident and an X-ray showed no injury. Although an incident report was completed the same day, the initial report lacked a documented submission time and there was no fax confirmation sheet or other proof of when it was sent. In contrast, the five-day follow-up report included a fax confirmation sheet, highlighting that only the initial report lacked verifiable time-stamped documentation.
Failure to Report Allegation of Neglect: A resident reported being left wet in bed for several hours and stated staff turned off the light and left while the call light was on. The Administrator and DON confirmed the grievance was an allegation of neglect, but it was not reported to the appropriate state agencies as required by the facility’s grievance policy.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
Failure to Report Allegation of Verbal Abuse: A cognitively intact resident reported that an NA complained while providing care and said she had “had enough of this place and these people.” The facility did not identify the statement as an allegation of mental abuse or report it to the appropriate state agencies, despite policy defining verbal conduct that causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, or degradation as abuse and requiring reporting when a resident perceives an event as abuse.
Failure to Timely Report Alleged Abuse and Injury Incidents: The facility failed to timely complete and submit required reportable documentation and follow-up for an injury incident involving a resident who fell during a CNA transfer and fractured a femur. The facility also did not report an alleged resident-to-resident altercation after a cognitively intact resident stated another resident hit her and took things from her room, despite staff observing the complaint and social work documenting fear and uneasiness.
A facility did not submit the required five-day follow-up report after investigating an allegation of sexual abuse involving a resident who lacked capacity. Although the initial report was made to authorities and interviews were conducted with the resident, staff, and other residents, the mandated follow-up documentation was not filed.
The facility did not submit required five-day follow-up documentation for investigations into suspected abuse and failed to report results to all necessary state agencies. For two residents, investigation files lacked timely follow-up, witness statements, and evidence of proper notification, as confirmed by the administrator.
The facility did not ensure that an allegation of verbal abuse involving a resident was reported immediately or within the required two-hour timeframe. Documentation lacked confirmation of when the incident was reported, and some witness statements were collected several days after the event. Staff confirmed the absence of required reporting documentation.
Failure to report a resident incident occurred when a resident sustained a hematoma to the head during a full body mechanical lift transfer. Staff noted one strap had not been unhooked and struck the resident’s head, and although education was documented, no Facility Reported Incident was completed for neglect.
A resident with diabetes experienced hypoglycemia and reported that a nursing aide responded inappropriately when he requested food, telling him to "shut up and go to sleep." Although the facility was aware of the incident and made changes to the resident's care, the allegation of verbal mistreatment was not reported to authorities within the required timeframe, resulting in a deficiency for failure to timely report suspected abuse.
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