Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to identify and timely report an allegation of neglect for one resident. The resident, who had a history of atherosclerotic heart disease and prior heart attacks, reported experiencing chest pain and difficulty breathing during the early morning hours. Despite informing staff of these symptoms multiple times, the staff did not take immediate action, and the resident was not sent to the hospital until several hours later. The resident later reported this incident to facility staff, expressing that their concerns were not addressed promptly and that they felt their life was at risk while waiting for assistance. A grievance form documented the resident's complaint, and the staff member who received the complaint reported it to their supervisor. However, the facility did not report the allegation of neglect to the State Agency until three days after the resident voiced the allegation. The facility's operating procedure required immediate reporting of suspected abuse or neglect to a licensed nurse and the State Agency hotline, but this protocol was not followed. The Director of Nursing Services confirmed that the delay in reporting was not acceptable and did not meet facility expectations.