A resident with respiratory failure and pneumonia, who was Full Code and not on hospice, was found during routine rounds and suspected to be deceased. Nursing staff assessed the resident, noted there was no rigor mortis, confirmed death, and did not initiate a code blue or any resuscitation efforts despite the resident’s Full Code status. The facility later treated this as a potential neglect incident but did not report it to the State Agency within the required two-hour timeframe, as confirmed by the regional QA director.
A resident with a hip fracture and anxiety reported to social services that a CNA had been rough, told the resident to take themself to the bathroom, and instructed them not to get out of bed until a specified early morning time. The allegation was received by facility staff in the late afternoon, but the incident report was not submitted to the State Agency until the following day, exceeding the required 2-hour reporting timeframe acknowledged by the DNS. The deficiency concerns this untimely reporting of an abuse allegation, despite the CNA’s denial of any abuse.
The facility failed to timely report two separate allegations of abuse and neglect to the State Agency. In one case, a resident with severe cognitive impairment and an anoxic brain injury developed significant swelling and bruising of the right knee, later confirmed as a fracture, which was known to staff but not promptly reported to administration or the State Agency. In another case, a resident with dementia and moderate cognitive impairment, dependent on toileting and personal hygiene, was allegedly left without incontinence care for an entire CNA shift, and this neglect allegation was not reported to the State Agency within the required two-hour timeframe. Leadership, including the DON and Administrator, acknowledged that both incidents were reported late.
The facility failed to timely report suspected resident-to-resident physical abuse to the proper authorities. Two residents, one with major depressive disorder and another with senile degeneration of the brain with anxiety and agitation, were involved in an altercation in which one resident struck the other with a reader stick after the other entered the room looking for personal items. A progress note documented that a resident reported being hit by another resident and was observed receiving a bandage to the knee. The Social Services Director completed an incident report and informed the administrator and DNS around midday, but the FRI was not submitted until several hours later, exceeding the required 2-hour reporting timeframe acknowledged by the DNS.
Two residents experienced alleged abuse or neglect that was not reported to the State Survey Agency as required. One resident with COPD and respiratory failure had an order for PRN morphine for shortness of breath and pain, but an LPN allegedly refused to administer the medication despite reports of screaming, dyspnea, and anxiety, and no FRI was filed despite the Administrator and a unit manager being aware. Another resident with a hip fracture and dementia was allegedly kept in a wheelchair at the nurse’s station for most of the night and repeatedly given coffee so an LPN would not have to address falls or incident reports, and the Administrator allegedly instructed staff not to submit an FRI, with no investigation or report completed.
The facility failed to timely report an allegation of physical abuse to the State Agency after a resident with cognitive impairment was documented as placing a pillow over another resident’s face and throwing heat packs at the resident while sleeping. Nursing staff reported the incident to the Administrator, who decided it would be investigated internally but not reported externally, and other RNs confirmed that administration determined the event was not reportable. The Administrator acknowledged awareness that all abuse allegations must be reported within two hours but did not do so, resulting in a deficiency for failure to report suspected abuse.
A cognitively intact resident with heart failure and kidney disease reported that a CNA/CMA spoke meanly, was rough, and treated them like a “bad dog,” and expressed fear of retaliation and discharge. An LPN acknowledged hearing this CNA/CMA be rude to the resident and to others, and stated that other staff had observed similar behavior, but she did not report it to management. The Administrator and DNS were later informed of the allegation and stated that staff are expected to notify them, the provider, and family when a resident feels abused, yet the allegation was not reported to the State Survey Agency as required.
The facility failed to report an incident of potential neglect involving an elopement to the State Survey Agency. A resident with anxiety and a cognitive communication deficit was found off premises near a busy street after their wander guard device was not functioning. An internal elopement investigation identified confusion and device failure as the root causes, but no Facility Reported Incident (FRI) was submitted. The former administrator reported she would not report an elopement because it was no longer on the FRI form, and the current administrator confirmed that no FRI was completed, despite the regional RN’s expectation that an FRI be submitted for such an alleged violation.
A resident with dementia and agitation physically struck a CNA and then alleged abuse by the CNA. An LPN assessed the resident and reported the allegation to management, but the facility did not report the abuse allegation to the State Agency within the required two-hour timeframe, and no investigation was initiated the same day.
A resident with dementia and behavioral disturbance was found with a bruise to the left eye, and staff could not determine the cause of the injury. Although a CNA reported the bruise to an LPN, the incident was not reported to the State Survey Agency in a timely manner, resulting in non-compliance with reporting requirements.
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