Failure to Report Allegations of Neglect
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of neglect for two residents. For one resident with diagnoses including spinal stenosis, heart failure, and osteoarthritis, and who required a two-person assist with a Hoyer lift, there was an incident during a transfer where the resident's leg was injured. The resident reported that her leg was trapped and that she called for help, but the aides did not notify a nurse or supervisor. The Director of Nursing later interviewed the resident, who provided a slightly different account, but no report of possible neglect was submitted to the state field office as required by facility policy and state law. For another resident with chronic obstructive pulmonary disease, muscle weakness, and a history of falls, who also required a two-person assist for transfers, an incident occurred where the resident was being transferred by a nurse aide and was lowered to the floor, resulting in a skin tear. The nurse aide involved was agency staff and used an incorrect level of assistance. Despite this, the facility did not report the possible neglect to the state field office as required. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the facility did not follow its own policies and procedures to report allegations of abuse and neglect for these two residents. The failure to report these incidents was in violation of both state law and the facility's own abuse prohibition policy.