Failure to Timely Report Suspected Abuse or Neglect to State Authorities
Penalty
Summary
The facility failed to immediately report an alleged violation involving possible abuse or neglect to the State Survey Agency (SSA) as required by policy. A resident with a history of atrial fibrillation and localized edema, who was receiving anticoagulant therapy, developed significant bruising, localized edema, and severe pain in the left lower leg. The care plan for this resident included instructions to use caution during transfers and bed mobility to prevent injury. On assessment, the resident was found to have a new onset of edema, the area was hot to the touch, and the pain was described as severe. The resident was subsequently sent to the emergency room, where an active bleed in the left lower extremity was identified. Despite these findings and the facility's policy requiring immediate reporting of all allegations of abuse or neglect to the SSA within 24 hours, the incident was not reported as required. Staff interviews and review of the facility's investigation confirmed that the incident was not reported to the SSA, constituting a failure to follow established protocols for reporting suspected abuse or neglect.