Failure to Timely Report Alleged Neglect to State Survey Agency
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of neglect in a timely manner to the State Survey Agency (SSA). A resident with multiple diagnoses, including stroke, parkinsonism, cognitive impairment, and incontinence, was found to have been left unsupervised outside on the smoking patio overnight without staff supervision or personal care. The incident was discovered by a registered nurse during morning medication rounds, after another resident indicated the individual was outside. The resident, who experienced periods of confusion, stated he was cleaning, but required assistance for toileting and transfers and was always incontinent. The facility's Self-Reported Incident (SRI) was created two days after the event was discovered, and the summary investigation confirmed the report to the SSA was not made until two days after the incident. According to facility policy, all alleged violations should be reported immediately, but not later than two hours if abuse or bodily injury is involved, or within 24 hours if not. The administrator confirmed the delay in reporting the incident to the SSA, which was not in accordance with the facility's policy.