Failure to Notify Resident Representative of Investigation Outcome
Penalty
Summary
The facility failed to notify a resident’s representative in a timely manner of the outcome of an investigation into an injury of unknown origin. Facility policy on Abuse, Neglect, and Exploitation, last reviewed November 7, 2025, stated that the facility would provide residents, representatives, and staff with information on how and to whom to report concerns, incidents, and grievances without fear of retribution, and would provide feedback regarding the concerns expressed. For Resident 1, who had dementia, depression, anxiety, restlessness and agitation, hallucinations, cognitive impairment, and dependence on staff for ADLs and transfers, the care plan documented behavior problems including yelling and refusal of care. On March 9, 2026, a nurse documented a skin tear with minor swelling and discoloration on the resident’s left ring finger, and the provider and responsible party were made aware of this injury of unknown origin. The facility conducted an investigation and determined that the injury resulted from the resident’s aggressive behaviors during care. However, upon interview on March 27, 2026, at 1:00 p.m., the Administrator confirmed that the resident’s representative was not notified of the outcome of the investigation once it was completed, contrary to the facility’s stated policy and resulting in a deficiency under 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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