Failure to Report Alleged Violations and Investigation Results
Penalty
Summary
The facility failed to comply with the regulatory requirement to report alleged violations involving neglect and mistreatment to the appropriate state agencies. In the case of Resident R1, who was admitted with a history of cerebral infarction resulting in left side weakness and incontinence, the facility did not report an incident where the resident was left in a soiled adult brief for several hours. The resident's family member informed the Nursing Home Administrator about the incident, but the facility did not notify the state agency as required. Additionally, the facility did not report the results of an investigation involving Resident R2, who sustained an injury when a housekeeper accidentally hit the resident with a cart, resulting in a broken toenail. Although the initial incident was reported, the follow-up investigation was not communicated to the state agency. These failures to report both the initial incident and the investigation results constitute a deficiency in the facility's compliance with reporting requirements.
Plan Of Correction
Event report has been made to the State Survey Agency for residents R1 and R2. A 30 day look back of facility grievances and incident reports was completed to ensure care concerns relating to neglect were reported and investigated per policy. Nursing Administration and Administrators have been educated on proper identification and timeliness of reporting; including to the State Survey Agency. NHA or designee will complete weekly audits of grievances and incident reports x 4 weeks then monthly x 2 months to ensure a timely investigation is initiated and reported to the state agency per policy. Results of audits will be reported in monthly QAPI Meetings for further recommendations.