Failure to Submit Follow-Up Investigative Reports to State Agency
Penalty
Summary
Facility staff failed to submit required follow-up investigative reports to the state agency for two residents following incidents involving allegations of neglect and injury of unknown origin. For one resident, who was cognitively intact according to the most recent MDS assessment, an incident report documented an allegation of neglect. However, review of facility records, including fax confirmation sheets and the incident file, did not show evidence that the final investigative report was sent to the state agency within the required timeframe. Interviews with facility staff, including the unit manager and administrator, confirmed the absence of documentation showing submission of the follow-up report as required by facility policy. For another resident, who was severely cognitively impaired and had a diagnosis including Alzheimer's disease, an incident report documented a bruise of unknown origin. Although initial reporting to the state agency was evidenced by fax confirmation, there was no documentation confirming that the follow-up investigative report was sent within five business days as required. Staff interviews indicated an understanding of the reporting requirements, but review of the fax confirmation sheets and incident documentation failed to provide evidence that the follow-up report was submitted to the state agency.