Failure to Timely Report Allegations of Neglect
Penalty
Summary
The facility failed to ensure timely reporting of allegations of neglect to the State Agency for two residents. For one resident with a history of cerebral infarction, hemiplegia, and major depressive disorder, an incident occurred during a transfer with a full mechanical lift when the sling detached, resulting in a fall and a comminuted fracture of the left arm. The incident was not reported to the State Agency until after the injury was confirmed by X-ray, which was outside the regulated reporting timeframe. The investigation later confirmed neglect due to a staff member deviating from the resident's plan of care by attempting the transfer alone. In another case, a resident with hemiplegia and dysphagia following a stroke made an allegation of neglect, which was documented in the facility's grievance log. However, this allegation was not reported to the State Agency as a separate incident and was instead included in another investigation without associating the resident's name. The administrator acknowledged that the allegation should have been reported when it was received.