Failure to Report Alleged Neglect and Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of neglect and an injury of unknown origin to the State Agency for two residents. For one resident with dementia and a history of behavioral disturbances, a new skin issue was observed on the forehead, described as a wound or burn of unknown origin. Documentation showed that the CNA and nurse noted the injury, notified the physician and family, and initiated wound care, but no investigation or report was submitted to the State Agency as required. The Director of Nursing and Administrator both stated they were unaware of the injury and confirmed that no investigation or reporting occurred due to this lack of awareness. Another resident, admitted with traumatic subdural hemorrhage, repeated falls, and Parkinson’s Disease, reported being left on a bedpan for several hours overnight without being cleaned up until the next shift. The resident, who was cognitively intact, relayed the incident to the Social Worker the following day. Facility documentation confirmed the concern, and interviews with the DON and Administrator revealed that the incident was not reported to the State Agency. The DON acknowledged that leaving a resident on a bedpan for an extended period without cleaning could be considered neglect. The facility’s own policy required immediate reporting of all alleged violations and substantiated incidents to the State Agency. In both cases, the required reporting and investigation procedures were not followed, resulting in a failure to comply with state regulations regarding the timely reporting of suspected abuse, neglect, or injuries of unknown origin.