Failure to Implement Abuse and Neglect Reporting Policy
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse and neglect for one resident whose records were reviewed. Specifically, a resident accused a respiratory therapist (RT) of yelling at her when she requested a larger cup of ice. The RT documented the resident's allegation in the progress notes but did not report the allegation to the Administrator, who is the designated abuse and neglect coordinator, as required by facility policy. The RT only informed her supervisor that the resident was unhappy, without mentioning the specific allegation of yelling. The facility's policy requires all employees to report any allegations of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property to the Administrator immediately, and if the allegation involves abuse or results in serious bodily injury, the report must be made within two hours. In this case, the Administrator became aware of the allegation two days later during a review of the RT's progress notes and subsequently reported the incident to the State Agency. Interviews confirmed that the RT and her supervisor were trained on abuse and neglect reporting, but the RT did not recognize the need to escalate the resident's allegation as required. The resident involved had significant medical needs, including acute and chronic respiratory failure with hypoxia, depression, anxiety, myopathy, dysphagia, and was dependent for care. She was NPO and received enteral nutrition, had a tracheostomy with mechanical ventilation, and was permitted ice chips under specific conditions. The incident occurred during the provision of ice chips, and the resident expressed concern about the RT's behavior, which was not promptly reported according to policy.