Failure to Timely Report Alleged Staff Misconduct to State Agency
Penalty
Summary
The facility failed to report an alleged violation involving mistreatment/misconduct within 24 hours to the State Survey Agency, as required by facility policy and federal regulations. Specifically, a registered nurse did not transcribe a physician's order to discontinue an anticoagulant medication and subsequently administered the medication without a valid physician order. The incident occurred on 07/17/25 and was discovered the following day, but the facility did not submit the initial report to the State Survey Agency until 07/24/25, well beyond the required 24-hour timeframe. The facility's policy mandates that all alleged violations involving abuse, neglect, exploitation, mistreatment, misappropriation of resident property, or injuries of unknown source be reported immediately to the Administrator and Director of Nursing, and to the State Survey Agency within 24 hours. The resident involved was admitted with multiple significant diagnoses, including congestive heart failure, chronic blood clots, anemia, ovarian and rectal cancer, and gastrointestinal bleeding. The resident was cognitively intact and required some assistance with mobility and toileting. The incident report indicated that the nurse administered the medication based on the resident's insistence, despite a physician's order to discontinue it, resulting in a medication error. The delay in reporting was attributed by the Nursing Home Administrator to concurrent issues and difficulty accessing the reporting system.