A cognitively intact resident with paraplegia and an indwelling catheter reported that an RN became angry when approached about a catheter bag and responded with profane, dismissive language, which was later substantiated as verbal abuse. The resident informed a CMA about the incident that evening, but the CMA did not immediately notify the administrator, honoring the resident’s request to self-report the next morning. The administrator was not informed until the following day and then had the resident complete a grievance form, after which the allegation was faxed to the state agency, resulting in the allegation not being reported within the required 2-hour timeframe.
The facility failed to follow its abuse reporting policy and regulatory requirements after a resident alleged that an LPN punched them in the shoulder, pushed their walker, and later verbally abused and cursed at them, causing fear, shaking, and prolonged crying. Grievances documented the physical and verbal allegations and the resident’s emotional response, but there was no timely response to the grievances. The DON acknowledged not reporting the abuse allegations to the state survey agency or local police within the required 2-hour timeframe and not notifying the state nursing board about the LPN, citing misunderstanding of the reporting timeframes and requirements.
A resident with a history of substance abuse and intact cognition was found in possession of suspected drug paraphernalia after staff observed them handling a small glass pipe with residue. The administrator obtained the item from the resident and disposed of it in the trash, and nursing documentation noted ongoing illicit substance use and reports that the resident provided substances to others despite prior education and revocation of self sign-out privileges. Although facility policy and state law require reporting suspected crimes and drug paraphernalia to law enforcement and the state health department, the DON and administrator acknowledged that no reports were made to either authority.
A cognitively intact resident with schizophrenia twice alleged being beaten by staff, first telling other residents they had bruises on their arms and back, and later calling 911 claiming staff were beating them with whips and chains. An LPN documented each allegation and reported them to leadership, and a police officer and LPN conducted a full body assessment with no bruising noted. Despite a written policy requiring immediate reporting of all suspected abuse to OSDH, the DON and administrator did not report either allegation to state authorities, instead relying on the absence of injuries and the police officer’s findings.
The facility failed to report an allegation of abuse to the state agency within the required 2-hour timeframe after a cognitively intact resident with CHF was found on admission to have bruises on the thighs and near the rib cage. APS arrived to investigate an abuse allegation involving this resident and informed facility staff of the investigation. The Administrator, DON, ADON, and Skilled Nurse Manager met, concluded the bruising was caused by a lift sling and not abuse, and decided not to report the allegation, believing that APS involvement as a state agency meant no separate report to OSDH was required.
A cognitively impaired resident with dementia, dependent on staff for transfers and wheelchair use, was allegedly yanked from a wheelchair and dropped forcefully onto a couch by a CNA after being described as combative with care. A family member and an RN both believed the CNA’s actions were abusive. Although the facility’s abuse policy required immediate reporting of suspected abuse to the Administrator or DON, the RN delayed reporting the allegation until the following morning, resulting in a failure to promptly report the suspected abuse.
The facility failed to follow its F609 abuse reporting policy requiring that allegations of abuse be reported to state and local authorities within two hours. A family member informed staff of an alleged act of abuse involving a resident, but the DON did not notify the administrator until a later staff meeting, and the administrator did not submit reports to the state survey agency and local law enforcement until several days after staff first learned of the allegation. Both the administrator and DON acknowledged in interviews that the allegation should have been reported when staff were initially informed by the family.
The facility failed to report two separate abuse allegations to state authorities within the two-hour timeframe required by its own abuse reporting policy. In one case, a CNA reported to the DON that another CNA had screamed at a resident with severe dementia in the dining room, but the incident was not faxed to the state until the following afternoon. In another case, a resident reported through gestures that their breast had been grabbed by another resident and indicated they slapped the other resident’s hand; although the charge nurse informed the DON and administrator, the allegation was not documented as reported to the abuse coordinator and was not faxed to the state until the next day. The administrator later acknowledged that these abuse allegations were not reported in a timely manner.
A resident with moderate cognitive impairment was transferred to the hospital for increased confusion, hallucinations, and respiratory changes after receiving one-half of a Xanax tablet from a family member, despite having no Xanax order in the EMR or MAR. An LPN learned from the family member that they had given the resident their own Xanax and relayed this to another LPN, who confirmed the incident with the family member and notified ambulance staff. The administrator was informed and discussed the event with the DON and a corporate nurse but decided it was not reportable because the state incident form did not specifically address this type of event, resulting in the failure to report an alleged criminal act involving a controlled substance to state authorities and law enforcement within the required 2-hour timeframe.
An allegation of abuse involving a resident with dementia and behavioral disturbances was not reported to the state agency within the required timeframe. The administrator conducted an internal investigation but decided not to submit an incident report, resulting in a failure to comply with mandatory reporting policies.
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