Failure to Report and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to report the results of an investigation regarding resident neglect to the State Survey Agency in a timely manner and did not thoroughly investigate allegations of neglect, affecting four out of five residents reviewed. In one case, a resident with multiple complex medical conditions, including diabetes, tracheostomy, and end-stage renal disease, experienced a significant change in condition after refusing insulin doses and being found on the floor with facial swelling. Despite clear changes in the resident's status, neurological checks were not performed, and the physician and family were not notified until after the resident was transported to the hospital, where the resident was later pronounced deceased. The facility did not notify the State Survey Agency of this incident within the required timeframe. In another instance, a certified nurse aide failed to provide timely care to three residents, leaving them soiled and not repositioned, which was discovered during wound rounds. The DON was aware of the aide's failure to provide care but did not report the incident as neglect or conduct a thorough investigation, citing the aide's generally good performance and lack of prior complaints. The aide admitted to being behind on her assignments and not seeking assistance, while the wound nurse confirmed the residents were found in soiled conditions, with one resident having a dislodged tube feeding and another with fragile skin exposed to wet sheets. The facility's policy required immediate investigation and reporting of suspected neglect, including thorough documentation and notification to state agencies within specified timeframes. However, the facility did not follow these procedures, as evidenced by the lack of timely reporting and incomplete investigations into the incidents involving the affected residents.