Failure to Timely Report Allegation of Neglect Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that an allegation of neglect was reported immediately, but not later than two hours after the allegation was made, for a resident who was reviewed for abuse. The resident, who had diagnoses including Parkinson's Disease with Dyskinesia, Morbid Obesity, Type 2 Diabetes Mellitus, and Urinary Tract Infection, was admitted and later readmitted to the facility. The resident was cognitively intact, requiring varying levels of assistance with activities of daily living, and had no skin conditions documented on the most recent MDS prior to the incident. On the day of the incident, the resident was found unresponsive with low blood sugar and was subsequently transferred to the hospital. During preparation for transfer, staff discovered the resident had been left on a bedpan for an extended period, resulting in skin injuries including abrasions and excoriation to the buttocks. The resident later reported being left on the bedpan for over three hours, confirmed by her own account and physical evidence observed by staff. The CNA assigned to the resident denied responsibility and subsequently left employment without providing a statement. The facility's investigation revealed concerns about the length of time the resident was left on the bedpan and the resulting skin injuries. Documentation and interviews indicated that the incident was not reported to the appropriate authorities within the required two-hour timeframe as outlined in facility policy and federal regulations. The failure to report the allegation of neglect in a timely manner constituted a deficiency in the facility's abuse and neglect reporting procedures.