Failure to Timely Report Resident Neglect to State Agency
Penalty
Summary
The facility failed to timely report an incident of resident neglect to the State Survey Agency as required by both facility policy and regulatory standards. Specifically, a resident with a history of right above-the-knee amputation, dementia, and cognitive communication deficit, who was assessed as requiring two-person assistance for transfers, experienced a fall in the bathroom after being transferred by a single nurse aide. The aide did not follow the resident's care plan or physician's order, instead relying on the resident's verbal response regarding transfer needs. The fall resulted in pain and swelling in the resident's left ankle, prompting a full assessment and x-ray order. Despite the facility's abuse policy mandating prompt reporting of neglect to appropriate agencies within five working days, the incident was not reported to the state agency at the time of occurrence or by the time of the survey interview. The Nursing Home Administrator confirmed that the event, which was determined through internal investigation to be neglect due to failure to follow transfer protocols, was not reported as required.