Failure to Notify Physician of Abuse Allegation
Penalty
Summary
The facility failed to notify the physician following an allegation of abuse involving a resident with severe cognitive impairment and multiple medical diagnoses, including anemia, hypertension, diabetes mellitus, thyroid disorder, traumatic brain injury, and alcohol-induced mood disorder. The resident was non-ambulatory, required substantial to maximal assistance with mobility, and was dependent on staff for locomotion in a manual wheelchair. An incident report documented that the resident was found with two dining room chairs placed behind his wheelchair in the common area to prevent tipping, which was reported as an allegation of abuse. Despite facility policy requiring immediate notification of the attending physician and medical director in such cases, there was no documentation in the incident report or the clinical record that the physician was notified at the time of the incident. Interviews with the DON and Administrator confirmed that the physician was not notified until several days later due to miscommunication and the suspension of the ADON. The delay in physician notification was acknowledged by facility leadership, and the required documentation was not present until after the incident had already occurred.