Failure to Timely Report Suspected Neglect to State Agency
Penalty
Summary
The facility failed to report an incident of neglect involving a resident within 24 hours to the local state field office, as required by both facility policy and regulatory standards. The incident involved a resident with diagnoses of muscle wasting, muscle weakness, and mobility abnormalities, who required a full body mechanical lift and two-person assistance for all transfers, hygiene, and repositioning. According to the care plan and physician orders, the resident was dependent on staff for bed positioning and movement. On the day of the incident, a nurse aide reported that the resident rolled out of bed while care was being provided, resulting in the resident being found on the floor and subsequently transferred to the hospital for further evaluation. Despite the facility's policies mandating immediate or within 24-hour reporting of suspected neglect to the State Agency, the incident was not included in the information submitted to the State Agency on the days following the event. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the required report of neglect was not made within the specified timeframe for this resident.