Failure to Timely Identify and Report Resident Neglect
Penalty
Summary
Staff failed to fully implement the facility's abuse and neglect policy by not promptly identifying and reporting an allegation of neglect involving a resident who was cognitively intact and required assistance with activities of daily living, specifically toileting. The resident was found in a soiled brief with bowel movement that had not been changed since early morning, despite the care plan indicating that checks and changes should occur every two hours. Multiple staff members, including CNAs and LPNs, observed and reported the resident's condition, noting that the brief was marked with a time indicating it had not been changed for several hours and that the resident had not received assistance throughout the day. Interviews revealed that concerns about the responsible CNA's failure to provide timely care were communicated among staff, with reports made to the nurse manager and the DON. The DON was informed of the situation but did not conduct a thorough investigation or speak directly with the resident or all involved staff. The administrator was notified later and was under the impression that the issue had been addressed, without recognizing the need for further investigation or reporting. The facility's abuse policy requires immediate reporting of suspected abuse or neglect to the administrator, with subsequent investigation and reporting to state agencies as mandated. In this case, the policy was not followed, as the allegation of neglect was not promptly reported or investigated, and key details about the resident's condition were not communicated to leadership. This resulted in a failure to ensure timely identification and reporting of neglect, as required by facility policy and regulatory standards.