Failure to Immediately Report Potential Neglect and Substantial Injury
Penalty
Summary
The facility failed to immediately report a potential case of neglect involving a resident with significant cognitive impairment who required supervision for toileting. The resident was found on the floor with a 2-inch laceration on the forehead, labored breathing, and signs of distress after being left unsupervised on the toilet, contrary to their care plan. The incident was unwitnessed, and the assigned nursing assistant did not provide the required supervision. The facility's investigation identified contributing factors such as poor lighting, confusion, drowsiness, impaired memory, and gait imbalance. The injury was substantial, occurring in an area not generally vulnerable to trauma. Despite facility policy and state guidelines requiring immediate reporting of suspected abuse, neglect, or substantial injuries to the state hotline, the incident was not documented as reported. Staff interviews confirmed the expectation to report such injuries, but the state reporting log did not reflect that the incident was reported as required. The failure to report the potential neglect and injury was identified during the survey and cited as a deficiency.