Failure to Report and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to report allegations of neglect to the Administrator and State Survey Agency for four residents reviewed for neglect. In one case, a resident with multiple complex medical conditions, including diabetes mellitus type I, tracheostomy, and end-stage renal disease, experienced a series of missed insulin doses due to refusal, followed by a significant change in condition. After being found on the floor unresponsive with facial swelling, the resident did not receive neurological checks, and neither the physician nor the family was notified of the change in condition until after the resident was transported to the hospital. The resident was later admitted to the hospital in critical condition and subsequently expired. There was no evidence that this incident was reported to the State Survey Agency as required. In another instance, a certified nurse aide failed to provide timely care to three dependent residents, resulting in them being found lying on soiled sheets, with one resident also having a dislodged tube feeding and another with wounds saturating the sheets. The DON was aware of the incident and disciplined the aide but did not report the allegation of neglect or conduct a thorough investigation, citing the aide's previous good performance and lack of complaints. The aide admitted to being behind on care and not seeking assistance, while the wound nurse confirmed the residents' compromised conditions and the importance of timely care. The facility's policy required immediate investigation and reporting of suspected abuse, neglect, or exploitation, with specific timelines for reporting to authorities. Despite this, the facility did not follow its own procedures in these cases, failing to notify the appropriate parties or conduct comprehensive investigations into the allegations of neglect. Staff interviews confirmed the lack of reporting and investigation, and documentation review supported the findings of unreported neglect.