Failure to Timely Report Suspected Neglect Incident
Penalty
Summary
The facility failed to immediately report a potential incident of neglect involving a resident who was left unsupervised in the spa room and subsequently found unresponsive, requiring emergency medical services and transfer to a higher level of care. According to the facility's Abuse Prevention policy, all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, must be reported immediately to the facility administration and the Division of Quality Assurance, with 'immediately' defined as not to exceed 24 hours after discovery. Despite this policy, the Nursing Home Administrator (NHA) did not report the incident to the State's Office of Caregiver Quality (OCQ) via the Misconduct Incident Reporting (MIR) system upon learning of the event. The resident involved had multiple medical diagnoses, including chronic obstructive pulmonary disease, bipolar disorder, chronic kidney disease, and other conditions, and was assessed as having intact cognition and requiring partial to moderate assistance with bathing and transfers. The NHA stated that after investigating the incident, they determined there was no willful intent and therefore did not report the event. The Director of Nursing (DON) confirmed that the incident was being reviewed internally but was not reported externally as required. This failure to report was identified during interviews and record reviews conducted by the surveyor.