Failure to Timely Report Resident Burn Injury
Penalty
Summary
The facility failed to ensure timely reporting of an alleged violation involving a resident who sustained a burn injury. On the morning of the incident, a resident with a history of heart failure, seizure disorder, and mood disorder, and who was assessed as moderately cognitively impaired and requiring assistance during meals, spilled hot coffee on their right hand. The incident was immediately observed by a Certified Nursing Assistant and reported to a Registered Nurse, who assessed the resident and noted redness but no blisters or swelling at that time. The nurse provided first aid and documented the incident in the huddle book but did not verbally report the incident to the oncoming shift, the nursing supervisor, or a physician, nor did they follow up on the resident's condition the following day. Two days after the incident, the resident was assessed by a physician and diagnosed with third-degree burns to the right hand and thumb. The incident was then reported to the facility administrator, who subsequently notified the New York State Department of Health. Interviews with facility staff confirmed that the incident was not reported to supervisory staff or the physician as required by facility policy and state regulations, which mandate immediate reporting of incidents involving serious bodily injury. The facility's own 'Abuse Prevention Policy and Procedure' requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, be reported immediately, but not later than two hours if the event involves abuse or results in serious bodily injury, or within 24 hours if not. In this case, the delay in reporting the incident to the appropriate authorities and facility leadership constituted a failure to follow established procedures for timely notification.