Failure to Immediately Report Resident Injury from Electrical Incident
Penalty
Summary
The facility failed to ensure that an alleged violation involving neglect or injuries of unknown source was reported immediately, as required by policy, for one resident who experienced an electrical incident. The resident, who had a history of cerebrovascular accident, seizure disorder, anxiety, and depression, reported being shocked while plugging in her phone charger, resulting in a charred mark and blisters on her finger and thumb. Despite the resident's immediate complaints and visible injuries, the nurse on duty did not report the incident as an allegation of neglect or injury to the Administrator at the time, only reporting an electrical malfunction. Interviews and record reviews revealed that the resident attempted to show her injuries to staff, including the nurse and social worker, and requested an incident report, which was not completed. The nurse focused on moving the resident to another room for safety but did not document or escalate the injury as a reportable event. The Administrator was only informed of an electrical malfunction and was unaware of the resident's injuries or the allegation of being shocked until questioned by surveyors at a later date. Facility policy required all staff to report known or suspected instances of abuse, neglect, exploitation, mistreatment, injuries of unknown source, or other reportable incidents to the Administrator. The failure to immediately report the resident's injury and allegation of being shocked constituted a violation of this policy and regulatory requirements for timely reporting of suspected neglect or injuries of unknown source.