Failure to Timely Report Alleged Neglect to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of neglect made by a cognitively intact resident was reported to the State Agency within 24 hours, as required. The resident, who required substantial to maximal assistance with toileting hygiene, reported that staff left them uncovered, unchanged, and wet for approximately two hours after a nurse had started to change their brief but did not return. The incident was not documented in the facility's incident or grievance logs, and there was no evidence that it was reported to the appropriate authorities. The resident stated that they had informed an Occupational Therapy Assistant (Staff V) about the incident, who in turn reported it to the charge nurse but could not recall who that was. Staff V also provided the resident with a grievance form and the contact number for the Ombudsman, but the resident declined to fill out the form. Facility leadership, including the Administrator and DON, were unaware of the incident until informed by surveyors and acknowledged that the allegation should have been reported. This lapse resulted in the failure to report the suspected neglect to the State Agency within the required timeframe.