Failure to Report Incident of Resident Self-Harm Attempt
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as misappropriation of resident property, for one resident reviewed for abuse and neglect. Specifically, the facility did not report an incident in which a resident was found with a call light cord wrapped around his neck, an event that met the facility's definition of an adverse event and neglect. The facility's Abuse Prohibition Protocol required immediate reporting of such incidents to the State agency and other authorities within two hours, but this was not done. The resident involved was an older male with a history of anxiety disorder, cerebral infarction, and hemiplegia, and had moderate cognitive impairment. Prior to the incident, there was no documentation or indication of suicidal ideation or behaviors in his medical record or care plan. On the day of the incident, the resident was found agitated, refused care, and wrapped the call light cord around his neck, expressing suicidal statements. Staff responded by removing the cord, notifying medical providers, and placing the resident on one-on-one supervision until he was transported to the hospital for psychiatric evaluation. Assessments showed no physical harm or marks on the resident. Interviews with staff confirmed that the resident had not previously expressed suicidal ideation and that the incident was promptly managed in terms of resident safety and medical response. However, the Administrator, who was responsible for reporting such incidents, did not report the event to the State agency, as required by facility policy and regulation. The failure to report the incident constituted a violation of the facility's abuse prevention and reporting protocols.