Failure to Timely Report Alleged Neglect and Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, as required by regulation. Specifically, an incident involving a resident with left-sided hemiplegia, vascular dementia, and aphasia was not reported to the State Agency within the mandated timeframe. The resident, who required substantial assistance for activities of daily living, experienced a slip in the shower chair while being transferred, which was not documented or reported at the time of occurrence. The incident was initially not recognized or documented by facility staff, and there was no evidence of a fall, skin, or pain assessment in the resident's records for the relevant dates. The resident later reported pain and a fall to hospice staff, who then notified the facility nurse and ordered pain medication. Despite this, the facility's incident and accident log did not reflect any record of the event, and the required reporting procedures were not followed. Interviews with staff revealed confusion and assumptions regarding who was responsible for reporting the incident, leading to a delay in notification to the Director of Nursing and the Administrator. The facility's policy required prompt investigation and reporting of all accidents or incidents, with documentation to be submitted to the Director of Nursing within 24 hours. However, in this case, the policy was not followed, and the incident was not reported to the appropriate authorities within the required 2-hour window. This lapse in procedure was confirmed through interviews and record reviews, which showed a lack of timely communication and documentation regarding the resident's fall and subsequent injury.