Failure to Report Suspected Neglect Following Resident Burn Incident
Penalty
Summary
The facility failed to ensure that all allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health for one resident. According to facility policy, any suspected or alleged abuse must be reported to the Department of Health, and investigations should include witness interviews and signed statements. However, for one resident with a history of heart failure and atrial fibrillation, this protocol was not followed after an incident involving a burn injury. The incident involved a resident who spilled coffee on herself while in bed, resulting in scattered intact blisters on her right abdominal area, under her right breast, and upper right thigh. The resident did not immediately report the injury to nursing staff, and when the incident was discovered, the Director of Nursing confirmed that it was not reported to the State Survey Agency as required by policy and regulation. This omission constituted a failure to report suspected neglect in accordance with state requirements.