The facility failed to demonstrate that an allegation of physical abuse between two residents was reported to authorities within the required two-hour timeframe. A resident was punched in the shoulder by a co-resident and an X-ray showed no injury. Although an incident report was completed the same day, the initial report lacked a documented submission time and there was no fax confirmation sheet or other proof of when it was sent. In contrast, the five-day follow-up report included a fax confirmation sheet, highlighting that only the initial report lacked verifiable time-stamped documentation.
Failure to Report Allegation of Neglect: A resident reported being left wet in bed for several hours and stated staff turned off the light and left while the call light was on. The Administrator and DON confirmed the grievance was an allegation of neglect, but it was not reported to the appropriate state agencies as required by the facility’s grievance policy.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A facility did not submit the required five-day follow-up report after investigating an allegation of sexual abuse involving a resident who lacked capacity. Although the initial report was made to authorities and interviews were conducted with the resident, staff, and other residents, the mandated follow-up documentation was not filed.
The facility did not submit required five-day follow-up documentation for investigations into suspected abuse and failed to report results to all necessary state agencies. For two residents, investigation files lacked timely follow-up, witness statements, and evidence of proper notification, as confirmed by the administrator.
The facility did not ensure that an allegation of verbal abuse involving a resident was reported immediately or within the required two-hour timeframe. Documentation lacked confirmation of when the incident was reported, and some witness statements were collected several days after the event. Staff confirmed the absence of required reporting documentation.
A resident with diabetes experienced hypoglycemia and reported that a nursing aide responded inappropriately when he requested food, telling him to "shut up and go to sleep." Although the facility was aware of the incident and made changes to the resident's care, the allegation of verbal mistreatment was not reported to authorities within the required timeframe, resulting in a deficiency for failure to timely report suspected abuse.
Staff failed to identify, report, and investigate repeated incidents of inappropriate resident behavior and family-reported concerns about pain management. Despite ongoing documentation and staff awareness of a resident entering female residents' rooms and another resident's unmanaged pain, the facility did not log or report these events to authorities as required by policy.
A facility did not thoroughly investigate an allegation of neglect after a resident was reported by his sister and an outside healthcare provider to have arrived at a medical appointment in soiled clothing with a strong odor of urine. The facility failed to contact the ambulance company or the receiving healthcare facility as part of their investigation, relying only on internal staff statements and not obtaining external documentation until prompted by a surveyor.
A resident's alleged physical abuse was not reported to state agencies within the required two-hour window, with the incident being reported more than ten hours after it occurred. Review of facility records and staff interviews confirmed that the delay was due to the incident not being promptly communicated to nursing staff, resulting in non-compliance with the facility's abuse reporting policy.
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