Failure to Timely Report Incident of Neglect
Penalty
Summary
The facility failed to report an incident of neglect in a timely manner, as required by regulations. The incident involved a resident who presented with dark coffee ground emesis on a specific date, and the nursing supervisor contacted the on-call physician to obtain verbal orders for medication. However, it was noted that the resident had a listed allergy to one of the medications prescribed. Despite the seriousness of the situation, the facility did not report the incident to the State Office until 10 days later, which is a violation of the requirement to report such incidents within 24 hours if they do not result in serious bodily injury. The resident involved had a medical history that included unspecified dementia, hypertension, and renal insufficiency. The facility's policy on abuse and reasonable suspicion of a crime mandates that any alleged violations must be reported immediately or within 24 hours, depending on the severity of the incident. During an interview, the Nursing Home Administrator and Director of Nursing confirmed the late reporting of the incident, acknowledging the facility's failure to comply with the timely reporting requirements.
Plan Of Correction
Immediately during the complaint survey, ERS submitted for Neglect on 12/18/2024. All allegations of abuse and neglect will be reported in the required parameters. DON/ADON will be re-educated on policy A-A-05 - Abuse - Resident and Reasonable Suspicion of a crime and timely reporting requirements. All staff will receive education regarding policy A-A-05 and timely reporting requirements. DON/ADON/Designee will audit all medication errors for abuse/neglect and timeliness of reporting weekly x4 and biweekly x2. Results of audit will be reviewed and evaluated at QAPI meeting.