Failure to Submit Required 5‑Day Investigation Report for Alleged Abuse/Neglect Incident
Penalty
Summary
The deficiency involves the facility’s failure to submit a required 5‑day follow‑up investigation report to the State Survey Agency after an allegation related to potential neglect/abuse was reported. A male resident with dementia and myelopathy, who had a quarterly MDS showing a BIMS score of 08 indicating moderate cognitive impairment, experienced a fall. During a subsequent care plan meeting, the resident’s family raised concerns to staff about the inaccuracy of the timing of documentation of the fall. The facility initiated an investigation, and the allegation was reported to the State Survey Agency through TULIP as an intake. The facility’s internal provider investigation report documented that the family’s concerns were addressed and that the investigation outcome was inconclusive. Record review of the TULIP website showed that, for the specific intake number associated with this allegation, no 5‑day report or provider investigation report had been submitted. The Administrator stated in interview that, to his knowledge, he did not send in the 5‑day investigation report for this incident and was unsure what had happened, speculating there may have been an internet outage but providing no confirmation. He acknowledged that the interventions were implemented but the report itself was not turned in to the State Survey Agency. This failure occurred despite a facility policy on Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, which requires the Administrator to provide a follow‑up investigation report within five business days of the incident.
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