Failure to Timely Report Suspected Abuse, Neglect, or Misappropriation to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of incidents to the State agency for two residents. In the first case, a resident with moderate cognitive impairment, multiple comorbidities, and total dependence on staff for activities of daily living was left on a bedpan for approximately eleven and a half hours. The nursing assistant who placed the resident on the bedpan did not return to check on her, nor did she inform the next shift that the resident was still on the bedpan. The subsequent nursing assistant also failed to check or change the resident during her shift. The resident was eventually found by a registered nurse with a bedpan still underneath her, resulting in a deep tissue injury. The incident was reported to the State agency about twelve hours after discovery, exceeding the required two-hour reporting window for incidents involving harm. In the second case, another resident with intact cognition and several chronic conditions was discharged from the facility and later attended a clinic appointment, bringing all her medications with her. It was discovered that she had been sent home with medication cards containing drugs prescribed to another resident. The resident reported taking these incorrect medications at home, which led to episodes of dizziness, multiple falls, and a hospital visit for low blood pressure. The clinic notified the facility of the medication error, but the incident was not reported to the State agency as required. Facility staff acknowledged that the incident should have been reported immediately upon becoming aware of it. Interviews with facility staff and review of the facility's abuse and neglect policy confirmed that the expectation was to report incidents of abuse, neglect, or significant bodily harm to the State agency within two hours, and all other reportable incidents within twenty-four hours. However, in both cases, the facility did not adhere to these timelines, resulting in a failure to meet regulatory requirements for timely reporting of suspected abuse, neglect, or misappropriation of resident property.