Failure to Timely Report Allegations of Neglect to State Authorities
Penalty
Summary
The facility failed to ensure that all allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health for two residents. According to facility policy, any allegation of abuse must be reported to the Administrator of Nursing immediately, and an investigation must be initiated without delay. In the case of one resident with muscle wasting, heart failure, and mobility issues, the resident reported being left wet with urine for several hours overnight and informed the morning charge nurse, who did not escalate the report to the Director of Nursing as required. The Director of Nursing was unaware of the allegation until informed by a surveyor. For another resident with muscle wasting, failure to thrive, and an above-knee amputation, both the resident and her family reported that concerns about being left in urine for an extended period were communicated to nursing staff but not reported to administration. The Unit Manager acknowledged awareness of the neglect allegation but did not report it to the Director of Nursing. Staff interviews confirmed knowledge of the reporting requirement but revealed that the allegations were not reported due to distractions such as surveyor presence. These failures resulted in non-compliance with state regulations regarding timely reporting of suspected abuse and neglect.