Failure to Timely Report Investigation of Resident Injury
Penalty
Summary
The facility failed to submit a written investigation of a possible instance of abuse or neglect to the state agency within the required 5 working days. According to facility policy, all alleged violations of abuse or neglect must be reported within 24 hours, and the results of the investigation must be submitted within 5 working days. However, for one resident with severe cognitive impairment and a diagnosis of dementia, the facility did not follow this protocol after an incident occurred. The resident, who was at risk for hot liquid accidents due to impaired cognition and confusion, spilled coffee on themselves while sitting at the dining room table. The incident resulted in a light pink area on the resident's abdomen, and an order was placed to monitor the burn. Despite this, the Director of Nursing confirmed that the investigation into the incident was not submitted to the state agency as required.