Failure to Timely Report and Investigate Alleged Abuse/Neglect Incident
Penalty
Summary
The facility failed to ensure that all allegations involving abuse, neglect, or misappropriation were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency. Specifically, an incident involving a male resident with chronic diastolic heart failure, severe intellectual disabilities, and cognitive communication deficit, who was admitted to hospice, was not reported. The resident was found to have tied a call light cord around his neck, an event that was not communicated to the State Survey Agency as required by regulation. Interviews with facility staff, including the ADON, NP, previous DON, and the administrator, revealed that the resident had not previously expressed suicidal ideations or intentions to harm himself, and assessments did not indicate such risks. The incident occurred while hospice staff were still present in the building, and the resident was subsequently placed on one-to-one supervision and sent for psychological evaluation after expressing a desire to harm himself. However, there was no documentation of an incident report or an internal investigation being completed for this event. A review of facility records and policies confirmed that the incident was not reported in the TULIP system, and the facility's Abuse Prohibition Policy required notification of such events to proper authorities according to state and federal regulations. The administrator acknowledged that not completing an incident report and investigation could have placed residents at harm if signs were not recognized and acted upon in a timely manner.