Failure to Timely Report and Protect Residents in Alleged Abuse and Neglect Incidents
Penalty
Summary
The facility failed to implement its Abuse, Neglect, and Exploitation policy and procedure in a timely manner regarding the reporting of alleged abuse and neglect incidents for three residents. In the first case, a resident did not receive medications for two days, and although the issue was communicated to the Abuse Coordinator on the day the event started, the official report to the Department of Children and Families (DCF) was not made until several days later. Documentation issues and failure to follow the process for placing medications on hold contributed to the delay. In the second case, a family member alleged neglect after observing that a resident with a history of anemia, atrial fibrillation, coronary artery disease, and heart failure was not given medication when experiencing high blood pressure. The allegation was received by the Nursing Home Administrator (NHA) via text, but the report to DCF was not submitted until two days later, exceeding the facility's policy requirement to report within 2 hours, but no later than 24 hours. The NHA confirmed the late reporting during an interview. The third case involved a newly admitted resident with a recent fracture and repeated falls, who self-reported not receiving pain medication until the day after admission. The NHA was informed of the allegation but did not report it to DCF until more than 24 hours later. Additionally, the facility did not implement protective measures for the resident during the investigation period. The facility's policy requires immediate protection of residents and timely reporting of all alleged violations, which was not followed in these instances.