Failure to Timely Report Resident Burn Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported within the required timeframes to the administrator and State Survey Agency. Specifically, an incident occurred in which a cognitively intact female resident with multiple medical conditions, including anxiety disorder, rheumatoid arthritis, muscle wasting, hypertension, and heart failure, was left unattended with a hot cup of liquid. This resulted in the resident sustaining second-degree burns to her right leg and experiencing pain. The incident was not documented in the facility's incident log, nor was it reported to the state agency as required. Record reviews revealed that the resident required total staff assistance with eating and had upper extremity impairment, yet was left alone with a hot beverage. After the incident, the resident was found in pain with a burn to her leg, and treatment was provided, including medication and wound care. However, the incident was not reported to Health and Human Services within the mandated 24-hour period, and there was no evidence of timely notification to the appropriate authorities. Interviews with staff indicated a lack of recall regarding the specifics of the incident and uncertainty about reporting responsibilities. Further interviews with facility leadership confirmed that the incident was not reported as required, with the current administrator and DON stating that the event occurred prior to their tenure and acknowledging the potential for additional harm due to the lack of reporting. Review of facility policies confirmed the requirement for immediate reporting of such incidents, but these protocols were not followed in this case.