Failure to Report Neglect Resulting in Resident Injury
Penalty
Summary
The facility failed to report an incident of neglect with physical harm to the State Survey Agency as required by federal and state law. A resident with paraplegia, neurogenic bladder, and bilateral above-knee amputations, who was cognitively intact and performed self-catheterization, sustained third-degree electrical burns after urine leaked into a power strip that had been placed in the bed. The administrator had previously removed an extension cord from the resident's room and provided a power strip, but there was no documentation of an assessment to ensure the resident could use the power strip safely, nor was there a care plan addressing the safe use of electrical devices or education provided to the resident about the risks involved. Medical records indicated the resident had a history of incontinence and required assistance with personal hygiene and toileting. Despite this, the care plan did not include interventions for intermittent catheterization or address the resident's refusal of care. Staff documented episodes of incontinence, and the resident was known to keep electronics in bed. After the incident, the resident was sent to the emergency room and admitted for treatment of the burns, which covered approximately 4% of the body surface area. Interviews with facility staff, including the former assistant director of nursing, former director of nursing, and the administrator, confirmed that the incident was not reported to the State Survey Agency. Staff also acknowledged that the resident's competency in self-catheterization was not observed or documented, and that no interventions or education regarding the safe use of electrical devices were implemented prior to the incident. The administrator admitted to not reporting the accident as required by regulations.