Failure to Report Alleged Neglect Following Resident Injury
Penalty
Summary
The facility failed to ensure that an allegation of neglect was reported to the State Survey Agency as required by both state law and facility policy. A female resident with severe cognitive impairment, anxiety disorder, communication deficit, and dementia sustained a laceration to her left lower calf during a transfer from wheelchair to bed, which required 13 stitches. The incident was witnessed by a CNA, who reported it to the on-duty LVN, and the resident was subsequently sent to the hospital for evaluation and treatment. Documentation confirmed the injury and subsequent care, but there was no record of a self-reported incident regarding neglect for this resident in the Texas Unified Licensure Information Portal (TULIP). Interviews revealed that the DON was informed of the injury and notified the Administrator, but neither the DON nor the Administrator reported the incident to the State Survey Agency. The Administrator stated he did not report the injury because it was witnessed, but later acknowledged, after reviewing neglect guidelines, that the incident should have been reported. Facility policy requires reporting all allegations of abuse, neglect, exploitation, mistreatment, and injuries of unknown source to the appropriate authorities, which was not followed in this case.