Failure to Report and Investigate Alleged Neglect
Penalty
Summary
An allegation of neglect involving a resident with multiple medical conditions, including heart failure, diabetes, and incontinence, was not reported to the state agency or the facility administrator as required by policy. The resident, who was always incontinent of bowel and bladder, requested incontinence care from a CNA after a bowel movement. The CNA informed the resident that assistance would be delayed due to staffing shortages. The resident subsequently blocked the CNA in the room, demanding immediate care, and an argument ensued. The resident was eventually assisted by an LPN and another CNA several hours later. Interviews revealed that the CNA reported the incident to the LPN, who in turn notified the ADON. The ADON did not investigate further or notify the administrator, and the DON was only partially aware of the situation. No formal investigation was conducted, and the incident was not reported to the state agency as required by the facility's abuse and neglect policy. The policy mandates immediate reporting and investigation of all alleged violations involving abuse or neglect, including notification of the administrator and state agency, and removal of the accused staff member pending investigation. The facility's failure to follow its own policy resulted in the lack of a timely and thorough investigation into the alleged neglect. Documentation of the incident was absent from the resident's clinical record, and no statements were collected from involved staff. The administrator confirmed that the required notifications and investigation did not occur.