Failure to Report Allegation of Neglect in Required Timeframe
Penalty
Summary
The facility failed to report an allegation of neglect within the required timeframe for one of four residents. The incident involved a resident with a history of dementia, muscle weakness, and repeated falls, who was admitted to the facility with a care plan indicating potential for skin integrity impairment. On December 16, 2024, the resident's daughter noticed a skin tear near the resident's right elbow and informed a Nurse Aide (NA) about it. The NA, unable to find a nurse, applied a clear bandage without cleansing the wound and forgot to inform the nurse about the incident. The Director of Nursing (DON) was aware of the situation but did not investigate or report it as neglect. The incident was documented in a facility Incident Report by a Licensed Practical Nurse (LPN), who noted a bruise on the resident's head and was informed by the resident's daughter about the skin tear. The DON confirmed that the facility did not report the allegation of neglect in the required timeframe, which is a violation of the facility's policy and state regulations.
Plan Of Correction
The incident that occurred with resident #R1 was reported to the Pennsylvania Department of Health and Adult Protective Services on 12/26/2024. A thorough review of all incidents current resident records will be conducted to identify any instances where the failure to report incidents, changes in condition, or abuse/neglect was noted. This review will cover the past 30 days from the date of the citation. All relevant incidents, including changes in a resident's condition, suspected abuse, neglect, or other critical information that should have been reported, will be documented and immediately reported to the appropriate agencies as per state regulations. Staff will also ensure that these incidents are fully documented in resident records. The Senior Director of Clinical Services will re-educate the director of nursing and executive director of health services on the abuse and neglect policy to ensure that instances that may be considered abuse or neglect are reported timely as appropriate to the designated agencies. The Director of Nursing and Executive Director of Health Services or their designees will re-educate team members by the compliance date on the need to report all incidents where there is a need for nursing intervention to ensure if there is any evidence of potential abuse or neglect that it gets reported immediately to nursing supervisors and addressed immediately with the abuse reporting compliance team. The Director of Nursing/designee will audit abuse and neglect incidents submitted through the PA Department of Health's Event Reporting System for timeliness of investigation and reporting for six weeks. The results of these audits will be shared with the Quality Assurance Performance Improvement Committee for review of trends that may require further action.