Failure to Timely Report Alleged Neglect Following Resident Heat Stroke
Penalty
Summary
The facility failed to report an allegation of neglect within two hours to the New Jersey Department of Health (NJDOH) after an incident involving a resident with multiple complex medical conditions, including multiple sclerosis, encephalopathy, dementia, and a history of falls and strokes. The resident, who had severely impaired cognition and required staff assistance for activities of daily living, was found outside on the patio during a heat wave, accompanied by a private companion. The resident became drowsy, unresponsive, and was found to have a high fever (103.8°F) and tachycardia. Staff provided cooling measures, administered Tylenol, and transferred the resident to the hospital as ordered by the physician. Interviews and documentation revealed that staff were unclear about how the resident ended up on the patio and whether appropriate supervision was maintained. The resident's family had previously indicated that the resident should not be outside unless accompanied by the companion. The incident investigation noted that staff did not observe the resident being taken outside and that there was typically a CNA assigned to oversee residents in the dayroom and patio area. The resident was ultimately diagnosed in the emergency room with heat stroke and transient alteration of awareness. Despite the circumstances suggesting possible neglect, the facility administration, including the DON and LNHA, decided not to report the incident to NJDOH, believing it did not constitute neglect. This decision was made even though the facility's own policy required the identification and investigation of all possible incidents of abuse, neglect, or mistreatment. The failure to report the incident as required constituted the identified deficiency.