Failure to Timely Report Resident Self-Harm Incident to State Agency
Penalty
Summary
Facility staff failed to notify the State Agency within the required 24-hour timeframe after an incident involving a resident who was found with self-inflicted lacerations on the right wrist using a disposable shaving razor. The resident, who had a history of Paranoid Personality Disorder, TIA, cerebral infarction, adult failure to thrive, and hereditary ataxia, was discovered with bloodied bed linens and expressed suicidal ideation. The incident was documented in the medical record, and the resident was assessed by a licensed nurse and subsequently transferred to the hospital for further evaluation. Despite the facility's policy requiring immediate or timely reporting of alleged abuse, neglect, or injury of unknown origin, the incident was not reported to the State Agency until after the required timeframe had elapsed. Staff interviews confirmed that the incident occurred before the resident's transfer to the hospital, but the report was not submitted until the following business day when facility leadership returned, indicating a lapse in timely notification as required by regulation.