The facility failed to timely report a resident-to-resident abuse allegation involving a resident who sustained a scalp injury and intracranial bleeding after a struggle over an iPad, and the initial report was not sent within the required 2-hour timeframe. The facility also failed to submit a required 5-day follow-up for a separate resident-to-resident abuse allegation in which one resident grabbed another resident’s arm, leaving fingernail marks; the DON could not locate the report, and the State Agency confirmed it was not submitted.
Delayed or Missing Abuse Investigation Follow-Up Reports: The facility did not ensure timely submission of five-day follow-up investigation reports for two residents after alleged resident-to-resident abuse incidents. One resident’s verbal abuse follow-up was submitted late, and another resident’s physical abuse follow-up was not found in the reportable file and was described as having been overlooked by prior leadership.
Delayed Reporting of Alleged Abuse: A resident-to-resident abuse allegation was documented after one resident reached between another resident’s legs and was redirected by a CNA, but the incident was not faxed to the state agency until more than 4 hours later. An interview with the Corporate Nurse and NHA confirmed the report was not made within the required 2-hour timeframe.
Failure to report allegations of abuse involving two residents and an NA. One resident reported another resident constantly threatened and intimidated her, while also describing increased anxiety tied to that resident’s behavior. The same resident also alleged an NA grabbed her by the pants and threw her back into bed, and both she and her roommate described ongoing fear and the NA being present on the hallway despite prior restrictions. The DON and Administrator acknowledged the allegations had not been reported.
The facility failed to report multiple incidents involving resident safety and possible abuse/neglect. A resident said staff left him overnight without changing his brief while he had diarrhea, another resident was served grilled cheese despite a mechanical soft diet and coughed after eating it, and two residents were involved in a cannabis gummy incident with altered mental status, red eyes, paranoia, and ER transfers. Records showed these events were documented, but the required reports and investigation were not completed.
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.
Failure to timely report allegations of potential verbal abuse. A resident reported hearing a CNA use a profanity-like word, but the allegation was not reported until much later than required. Surveyors also found an unreported statement alleging that two NAs called residents names, ignored call lights, and treated residents in a mean or hostile manner; the administrator confirmed these allegations had not been previously reported or investigated.
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.
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