The facility failed to report an allegation of physical abuse to law enforcement as required by its abuse reporting policy. A cognitively intact resident with dementia, anxiety, bipolar disorder, and major depressive disorder reported refusing a shower when a NA placed a lift sling under them, after which the situation escalated and both the resident and the NA exchanged punches. Skin assessments documented multiple new bruises on both of the resident’s arms and hands that were not present the prior day. Although facility policy required timely notification of law enforcement for such allegations, documentation in the abuse report form and EHR showed no law enforcement notification, and facility leadership confirmed that the incident and bruising were not reported to police.
A facility failed to submit a thorough investigation to the state agency after a resident experienced an unwitnessed fall while attempting a self-transfer, later being found to have a left femoral neck fracture, low Hgb, low BP, and pneumonia. The resident had multiple diagnoses, including dementia, COPD, ataxic gait, osteoarthritis, and weakness, was care-planned for wheelchair use at all times, and had a history of multiple falls and recent illness with fever and low O2 saturation. Although the DON identified weakness and low Hgb as possible causes of the fall, the investigation report submitted by the ADM did not include weakness as a cause and omitted key information such as the resident’s diagnoses, documented symptoms, BP findings, and whether medications had been reviewed.
The facility failed to report an unexpected, untoward death of a resident to the State Agency within required timeframes, as mandated by its abuse prevention policy and state licensure rules. The resident had multiple serious conditions, including end-stage kidney disease requiring hemodialysis, chronic respiratory failure, heart failure, diabetes, and COPD, with moderately impaired cognition and a care plan addressing dialysis needs and fistula monitoring. Nursing notes documented the resident was found nonresponsive in bed with no pulse or respirations, blood around the body and on the floor, a small open area at the bottom of the left arm fistula, and blood on the fingertips of the right hand, with no trauma or sharp objects present. The DON acknowledged the death was unanticipated and that, although an internal investigation was completed, the facility did not submit the incident or investigation results to the State Agency as required.
The facility failed to report an allegation of neglect to the State Agency within the required 2-hour timeframe after a family member alleged that the facility caused a resident’s death through medical neglect. An LPN assessed the resident and found no heartbeat, while the resident’s advance directive and current orders still indicated CPR, and a hospice consult had been ordered but not yet completed. The administrator was informed of the situation, spoke with local law enforcement about the family member’s accusations, but did not notify the State Agency until the following day, which was confirmed by the administrator as not meeting the required reporting timeframe.
A resident with hemiplegia, hemiparesis, and frequent urinary incontinence, but intact cognition, was the subject of a grievance from a family member alleging the resident remained wet for over four hours and that requests for assistance were ignored until other staff were found. The resident reported waiting up to about 45 minutes after activating the call light, sometimes resulting in incontinence, and another family member described a call light going unanswered for up to four hours. Although the DON recognized this grievance as an allegation of potential neglect and stated an investigation was conducted, it was not documented, and the event was not entered on the reportable incident log or reported to the State Agency. The ADM stated the allegation was not reported because they believed that, without a resident outcome, it did not require reporting, contrary to facility policy and regulatory requirements for timely reporting of alleged neglect.
A resident with a documented DNR order and intact cognition became unresponsive in the dining room, and staff initiated CPR despite the existing DNR. During the code, staff recognized the resident’s DNR status but continued CPR and transferred the resident to acute care. The event, which violated the resident’s expressed wishes and physician orders, was not reported to APS, even though the facility completed an internal investigation.
The facility failed to meet regulatory and policy timeframes for reporting an incident of resident-to-resident abuse and submitting the investigation results. An incident of abuse occurred between two residents, one with dementia, weight loss, unsteadiness, and type 2 DM, and another with COPD, pneumonia, bladder dysfunction, and heart failure. The DON and ADM were notified by phone the day of the incident, but the ADM did not notify the State Agency until days later, beyond the required 24 hours, and the written investigation report was also submitted after the 5-working-day deadline.
The facility failed to submit complete and thorough investigative reports to the State Agency for two residents who sustained major injuries from falls. In one case, a resident fell in their room, resulting in head laceration and fractures of the wrist and femur, and the report submitted attributed the fall to non-compliance with transfers but omitted documented post-hospital interventions. In the other case, a resident had an unwitnessed fall in a sitting area, leading to facial lacerations and a fractured nose, and the report submitted lacked a thorough investigation of the circumstances surrounding the fall.
Facility staff failed to timely report an elopement to the State Agency as required by policy and state regulations. A resident with severe cognitive impairment, who required total assistance with toileting and extensive assistance with dressing and hygiene but could ambulate independently, opened a back door, exited into the parking lot, and triggered a door alarm. A NA first checked the front door, then the back door, and upon opening it observed the resident walking in the back parking lot and redirected the resident inside. Review of facility reporting records showed the incident was not reported within required timeframes, and the DON confirmed the elopement had not been reported as it should have been.
Failure to report an allegation of potential physical abuse: A resident with intact cognition reported feeling manhandled and said they told the DOR about the incident. The DOR confirmed the report but did not notify the Administrator or DON, and the Administrator confirmed the concern should have been escalated and that no reports of resident mistreatment had been made.
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