Failure to Timely Report Alleged Neglect and Injury of Unknown Source
Penalty
Summary
The facility failed to ensure that all alleged violations involving neglect, including injuries of unknown source, were reported immediately, but no later than two hours after the allegation was made if the events involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury. Specifically, the facility did not report an incident involving a resident who was found with a call light cord around his neck and expressing suicidal ideations. The event was not reported to the administrator and the State Survey Agency in accordance with state law and the facility's established procedures. 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 were no documented suicidal ideations or behaviors in his medical record, care plan, or hospital records. On the day of the incident, the resident was found agitated, refused care, and wrapped a call light cord around his neck while expressing a desire to die. Staff responded by removing the cord, clearing the room of potentially harmful items, and placing the resident on one-on-one supervision until he was transported to the hospital for psychiatric evaluation. No physical injuries were noted during the head-to-toe assessment. Interviews with staff confirmed that the incident was immediately addressed in terms of resident safety and medical response, but the required reporting to the State Survey Agency was not completed as per regulatory requirements. The administrator, DON, and other staff acknowledged that the administrator was responsible for reporting such incidents, and that the event was not reported because the administrator did not consider it reportable. The facility's current abuse prohibition protocol required all adverse events, including those with risk of serious injury, to be reported, but this protocol was not followed in this case.