Failure to Timely Report Alleged Neglect to State Agency
Penalty
Summary
An allegation of neglect involving a resident with multiple sclerosis, epilepsy, depression, anxiety, and severe cognitive impairment was not reported to the State Agency (SA) as required. The resident, who was dependent on staff for activities of daily living and had a care plan addressing communication difficulties and skin integrity risks, did not receive incontinence care until late in the 7 AM to 3 PM shift. A nursing assistant reported this delay in care to the RN supervisor at the end of the shift, and the supervisor submitted a written statement by sliding it under the office door of the Director of Nursing Services (DNS) or Assistant DNS (ADNS), but did not confirm receipt. The DNS later acknowledged awareness of the allegation but was unable to locate or provide an investigation report and confirmed that the concern should have been reported to the SA. The facility's abuse policy required immediate reporting and investigation of abuse or neglect allegations, including notification of the administrator and DNS or designee, and prompt reporting to appropriate authorities. The failure to report the allegation to the SA was only rectified after surveyor inquiry.