Failure to Report Possible Neglect Incident to State Agency
Penalty
Summary
The facility failed to report an incident of possible neglect involving a resident who experienced increased pain and knee swelling following care. The DON stated that she became aware of the resident's complaints and swelling several days after the incident, and upon investigation, learned that the nurse providing care had heard a loud pop while moving the resident in bed for wound care. The nurse did not report the incident to the DON or the medical provider, nor was the event documented in the resident's medical record. Additionally, there was no incident report completed, and the event was not reported to the State Agency as required. Review of facility self-reports confirmed that no incidents for this resident were reported during the relevant time period.