A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with ataxia fell from a facility van when the rear door opened during transport, after the transport driver failed to properly secure the resident. The driver did not immediately notify the DON or administrator, despite facility policy requiring all incidents and accidents to be reported at once. The DON learned of the event later and informed the administrator, who was responsible for reporting alleged neglect to the state agency within 24 hours. The administrator initially did not consider the event neglect and did not report it, although she later acknowledged that the failure to secure the resident in the van, resulting in the fall, met the facility’s definition of neglect and should have been reported within the required timeframe.
A resident reported that another resident entered her bathroom, shoved a door into her, pushed her against a wall causing her to fall, got on top of her, pulled her hair, and called her a derogatory name before staff intervened. The resident stated she informed an LPN of the physical and verbal abuse, but there was no documentation of the incident in her record and no internal incident or abuse report was initiated. The LPN and the RN weekend supervisor, both trained in abuse reporting, chose not to report the allegation to administration or complete required documentation because they did not witness the event and believed it did not require reporting, despite facility policy and definitions of abuse requiring that all such allegations be reported and investigated.
The facility failed to ensure that witnessed physical and verbal abuse of a resident by an LPN was reported to the administrator and state agency within the required 2-hour timeframe. An LPN repeatedly struck a resident’s face, head, and shoulders with a closed fist, placed her knee on the resident’s neck, attempted to drag the resident by his shirt, and yelled profanities at the resident in front of staff and another resident. The LPN also directed CNAs not to assist the resident from the floor or from his chair, and the CNAs left the unit for several minutes and later left the LPN unmonitored with access to all residents. Despite facility policies requiring immediate reporting of suspected or actual abuse, the CNAs who witnessed or were informed of the abuse did not notify administrative staff until the following day, and the administrator acknowledged the incident was not reported to the state agency within the mandated timeframe.
The facility failed to follow its abuse and injury reporting policy by not immediately informing the Administrator of an unwitnessed fall that resulted in serious bodily injury. A resident with multiple medical conditions, intact cognition, and no recent falls was found by an LPN lying face down on the floor, unresponsive, with a hematoma and laceration to the head and blood on the floor, and was sent to the ER where the resident later died. The DON was notified around shift change and then contacted the Corporate Administrator later that morning, but only reported that the resident had a fall, omitting that it was unwitnessed and involved serious head trauma, contrary to the requirement to report such events within two hours with full details.
The facility failed to report an injury of unknown origin with serious bodily injury to the State Survey Agency as required by its abuse reporting policy and state law. A cognitively impaired resident with multiple diagnoses, including dementia and a history of repeated falls, was found with bruising and swelling to the lower leg and later diagnosed by x-ray with acute fractures of the tibia and fibula. The resident could not explain the cause of the injury, and the facility’s investigation did not identify a cause, meeting the policy’s definition of an injury of unknown origin. Despite this, the Administrator, who was responsible for such notifications, did not report the incident to the State Survey Agency.
The facility failed to timely report an injury of unknown source with serious bodily injury to the State Survey Agency as required by its abuse and incident reporting policy. A resident with cognitive impairment, upper and lower extremity limitations, and dependence on staff for transfers and ADLs complained of left shoulder pain, and an NP ordered an x-ray that showed an age-indeterminate proximal humerus fracture with displacement, later described by the physician as an acute displaced angulated fracture. Despite the resident’s condition and the unclear origin of the injury, the Administrator and DON concluded the injury was not of unknown origin based on the resident’s osteoporosis diagnosis, did not suspect abuse, and did not report the incident through the State Incident Management System within the required 2-hour window, resulting in delayed reporting to the State Survey Agency.
A resident with multiple comorbidities, moderate cognitive impairment, and dependence on staff for ADLs was found to have a large bruise on the right shoulder/armpit area, with no clear cause identified and while receiving Eliquis. Nursing staff documented the bruise, noted the recent use of a sling lift and the resident’s history of easy bruising, and verbally educated CNAs on positioning techniques. The DON and Administrator were aware of the injury and treated it as an injury of unknown origin, but they did not report it to the State Agency within the required 24-hour timeframe, contrary to the facility’s incident/accident and abuse reporting policies.
A facility failed to report an allegation of verbal abuse within the required timeframe after a third-party staff member witnessed a staff member curse at a resident in front of others. The administrator did not submit the required report to the Department of Health, citing the delay in notification and the resident's lack of recollection, despite facility policy mandating immediate reporting of such incidents.
A resident with severe cognitive impairment was subjected to alleged verbal abuse by a CNA, which was reported by another CNA to nursing staff. Although the incident was eventually brought to the attention of administration, the required abuse report was not submitted to the State Survey Agency within the mandated two-hour window. Staff interviews confirmed that facility policy required immediate reporting, but the administrator delayed the report due to other facility demands.
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