The facility failed to submit required investigation findings to the State Survey Agency (SSA) within 5 working days for multiple abuse and elopement incidents. In one case, a resident kicked another resident’s feet, and in another, one resident kicked another in the legs while both were in wheelchairs; in both situations, the facility did not provide timely or, in one case, any investigative findings to the SSA. The facility also reported two separate elopement events for a resident but did not submit final investigation reports for either incident. A staff member reported that another staff member, who was absent during the survey, was responsible for SSA reporting, and confirmed the expectation to report all investigation results within 5 working days per facility policy.
The facility failed to timely report several allegations of abuse and neglect to the administrator and State Survey Agency as required by its policy. In one case, a resident experienced inadequate hygiene care and lack of monitoring after vomiting, identified later on video, but the allegation was not promptly reported. In another incident, a staff member’s physical contact caused a resident to lose balance and be assisted to the floor, and both the involved staff and a witness delayed notifying the nurse. In a third situation, a staff member allegedly verbally abused two residents by threatening a cold shower and ordering a resident to sit down and be quiet, and the witnessing staff member did not report these events until days later, resulting in late external reporting.
Two residents were involved in an altercation over a weekend, and the nurse on duty did not promptly notify the DON or Administrator, resulting in the incident not being recognized by leadership until a chart review was conducted later. An attempt to submit the initial abuse allegation report to the State Survey Agency was made but not successfully saved in the reporting system, and no immediate resubmission occurred. The full investigation, including the initial report, was submitted several days later, causing the initial abuse report to be filed late, despite staff having received prior abuse reporting training.
A resident reported that a former staff member repeatedly left the call light unanswered for extended periods, did not provide needed ADL assistance, and encouraged the resident to sign refusal-of-care forms, resulting in the resident soiling briefs before being asked to ambulate to the restroom. Another staff member stated that no care concerns had been brought to their attention and acknowledged that the alleged abuse and neglect were not reported. When surveyors requested IDT notes, root cause analysis, reporting, and investigation documents related to the staff member and this resident, the facility was unable to provide any documentation, indicating the allegation was not timely reported to the State Survey Agency or investigated.
The facility failed to timely report an allegation of sexual abuse and to submit investigation findings for multiple abuse-related events to the State Survey Agency. A resident with a history of inappropriate contact with female residents was observed placing his hand on another resident's thigh while assisting with feeding; a staff member intervened and reported this to a nurse, who documented the behavior but did not report it as required. In separate incidents, a verbal altercation between two residents and a resident's allegation of verbal abuse by a staff member were reported as events, but the required investigation findings were submitted to the state one day past the regulatory deadline, despite internal alerts and established abuse-reporting policies.
The facility failed to submit required investigative findings to the State Survey Agency within five working days for multiple reportable events, including verbal mistreatment in a dining room, allegations of inappropriate touching between residents, and several elopement incidents. Staff responsible for reporting acknowledged that final investigation reports were submitted late, and one staff member cited being reassigned to kitchen duties as a reason for a delay. These actions did not follow facility policies that require the administrator or designee to report investigation results to appropriate agencies within the specified timeframe.
The facility failed to report a resident-to-resident abuse incident to the State Survey Agency within the required 24-hour timeframe. Staff reported that incidents must be reported within 24 hours, with 2-hour reporting for serious bodily injury and investigation results due within 5 days, and the facility’s written policy reflected these requirements. However, an altercation between two residents was reported more than 24 hours after it occurred, contrary to the facility’s mandatory reporting policy and the timelines described by staff.
A resident experienced an unwitnessed fall with injury, and the facility failed to submit the investigation findings to the State Survey Agency within the required five-day period. The staff member responsible for reporting was filling in for another and was not educated on the reporting requirements, resulting in a two-day delay.
The facility did not report allegations and findings of abuse within the required timeframes for a resident involved in a physical abuse incident with staff and for two residents involved in a verbal altercation. Delays were attributed to technical issues and failure of staff to promptly report incidents, resulting in late notifications to the State Survey Agency.
The facility did not submit required reports to the State Survey Agency within mandated timeframes for several incidents, including unwitnessed falls with injury and an incident of staff-to-resident abuse. In each case, reports were filed late despite prompt internal notifications and investigations, with staff unable to explain the delays or clarify reporting responsibilities.
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