A resident with altered mental status developed bilateral wrist discoloration and swelling during ADL care when a CNA reported the resident was resisting and bumped both wrists against a wheelchair during transfer. An RN completed an incident report and nursing note documenting the injury, assessment, and physician notification with an order for x-ray. Facility leadership later acknowledged that this event, which met their policy criteria for an allegation requiring reporting within two hours if involving abuse or serious bodily injury, was not reported to the state survey agency, contrary to the facility’s written abuse, neglect, and exploitation policy.
Facility staff failed to timely report an allegation of abuse involving a resident with moderately impaired cognition and a diagnosis including malignant neoplasm of the colon. The resident reported being shoved back into bed by staff after nearly falling, and a facility synopsis documented that she was shoved twice by two staff members while being assisted to bed. The incident date and the report date in facility records showed a five-day delay before the allegation was reported to state agencies. Staff interviewed during the survey stated they were not aware of the incident, and leadership provided no additional information about the delay, resulting in a deficiency for failure to promptly report suspected abuse.
The facility failed to follow its abuse policy by not timely submitting the final 5‑day investigative summary of an altercation between two residents to the state survey agency and by not notifying the involved resident’s representative of the investigation outcome. After a resident reported being struck in the eye by another resident during a struggle over a reacher/grabber tool, staff separated the residents, documented bruising and swelling to the injured resident’s eye, and initiated required assessments and notifications. The initial incident report was faxed to required agencies, and the final 5‑day summary was successfully sent to adult protective services and the ombudsman, but multiple fax attempts to the state survey agency failed, with no documented re‑attempts on subsequent business days as required by policy. The injured resident was later transferred to the ED and did not return, and there was no documentation that the resident or the resident’s representative was informed of the investigation’s outcome.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
A resident with dementia and weakness was found lying on the floor with right leg pain after an unwitnessed incident and was emergently transferred to the hospital. Facility documentation showed the resident was not interviewed about the event, and leadership later confirmed that the former Administrator did not report this injury of unknown origin to the State Survey Agency as required. Review of facility policy showed that all injuries of unknown source, including those involving possible abuse or serious bodily injury, must be reported immediately, but not later than two hours after the allegation is made.
A resident with severe cognitive impairment and behavioral disturbances became combative during care with a CNA, resulting in a skin tear to the resident’s finger and a bruise under the eye. The resident later stated to an RN that the CNA had punched her. The RN reported the incident and allegation to an LPN, who said the DON would be notified but did not contact the DON that night. The DON only learned of the allegation the next morning, and the SSA was not notified until later that day, contrary to facility policy requiring immediate reporting and notification within two hours for abuse allegations.
Facility staff failed to investigate an allegation of abuse after a resident with paraplegia and depression, who was cognitively independent, was reported by another resident to have pulled a knife and made him fear for his life. Nursing staff notified the DON, contacted 911, and attempted to search the resident’s belongings, but the resident refused a full search and left the unit. Despite the Administrator’s stated procedure and facility policy requiring prompt initiation of an investigation and reporting of all abuse allegations, no incident report or investigation was completed or documented for this event.
Failure to Timely Report Alleged Abuse Incidents: The facility did not report multiple alleged abuse incidents involving residents within the required 2-hour timeframe. In one case, a CNA observed one resident in another resident’s room with inappropriate contact, but the report was not sent to the SA until the next day. In other incidents, allegations of sexual abuse and abuse between residents were reported many hours or days late, and the DON confirmed the reports were not submitted on time.
A resident with severe cognitive impairment and an active elopement care plan, including a wanderguard, was reportedly found outside the building by a visitor, inadequately dressed and visibly cold, while an alarm sounded and no staff were present at the entrance. The visitor stated they could not reach staff by phone, contacted 911, and later informed the DON of the incident. Facility leadership initially denied receiving any report of the event, and the DON later described a prior call with a similar-sounding resident name that they could not match to any resident. Despite a written abuse/neglect policy requiring prompt reporting of all alleged neglect to the administrator and regulatory agencies, the allegation that a resident had been outside unsupervised was not reported as required.
Failure to Timely Report Abuse Allegations: A resident was involved in two resident-to-resident altercations in which one roommate reported being punched and another resident was struck in the face with a padded sewing box. Facility records showed the abuse allegations were not reported to the state agency within the required 2-hour timeframe, and the DON stated the incidents were probably not brought to her attention until the next day.
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