Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and report potential allegations of abuse and/or neglect to the State Survey Agency as required for three residents. Resident 1, who had a lower leg amputation and was able to communicate needs, filed a grievance stating that their roommate was left in feces all night without being changed, and reported other incidents where it took up to two hours for staff to respond. This allegation of potential neglect was not logged or reported to the State Survey Agency. Resident 2, with diabetes and depression, also filed a grievance indicating they were left on a bedpan from morning until the evening shift and not checked on again until the following morning, despite needing regular changes due to risk of skin breakdown. This concern was similarly not reported as required. Resident 3, admitted after spine surgery and able to communicate needs, reported excessive delays in call light response and a significant delay in receiving pain medication upon admission, stating their pain was severe and the facility had run out of their medication. This grievance was also not logged or reported to the State Survey Agency. Interviews with facility staff confirmed that these allegations of potential abuse and/or neglect were not properly documented or reported, as required by regulation.