Failure to Report and Investigate Suspected Neglect Related to Pain Management
Penalty
Summary
A deficiency occurred when the facility failed to report a potential allegation of neglect involving a resident who was cognitively intact and required supervision for functional tasks. The resident, who had a history of acute pain due to trauma, osteoporosis with pathological fracture, and muscle weakness, requested Tylenol for pain during the night shift. The nurse on duty denied the request, stating she did not believe the resident was in pain, and did not offer any alternative interventions. The resident waited until the next shift to request pain relief and was found to be in significant pain, assessed as 8 out of 10, and was in tears. Facility policy required that any suspicion or observation of abuse, neglect, or misappropriation of resident property be immediately reported to the appropriate authorities and thoroughly investigated. The policy also specified that such incidents should be reported to the unit manager or supervisor, and subsequently to the Administrator or DON. In this case, the incident was documented as a grievance by a staff member, but there was no evidence that it was reported as a potential neglect incident or that a full investigation was conducted as required by policy. The Director of Nursing, upon review of the grievance and medication administration records, acknowledged that the nurse did not adequately manage the resident's pain and that the incident should have been investigated and reported as neglect. The incident was not reported to the state agency, and a full investigation was not completed, which constituted a failure to follow facility policy and regulatory requirements for reporting suspected neglect.