Failure to Timely Report Resident Incident to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an incident involving a resident with Alzheimer's disease, moderately impaired cognition, type 2 diabetes, malnutrition, and hypertension. The resident left the facility in his own vehicle, became lost, and was returned by a police officer. Upon return, the resident was unable to recall the incident, and his responsible party was notified by the police officer. The incident was documented in the resident's progress notes and care plan, which was updated to address the resident's inability to return to the facility without assistance and to remove access to vehicle keys. Despite facility policy requiring all alleged violations involving abuse, neglect, or exploitation to be reported to the Administrator and state agency within specified timeframes, the Director of Nursing (DON) did not notify the Administrator of the incident, citing the resident's safe return and lack of injury as reasons. The Administrator was not made aware of the incident until days later and did not report the event to the state survey agency (HHSC) for similar reasons. Review of the Texas Unified Licensure Information Portal (TULIP) confirmed that no incident report corresponding to this event was submitted by the facility. Interviews with facility staff and the resident's responsible party confirmed the sequence of events and the lack of timely notification to both the Administrator and the state agency. Facility policy specifically required reporting of such incidents within 24 hours, even if the event did not involve abuse or result in serious bodily injury. The failure to report the incident as required constituted a deficiency in the facility's compliance with state regulations regarding the reporting of alleged violations.