Failure to Timely Report and Respond to Alleged Neglect of Resident Requesting Hospital Transfer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, as required by regulation. Specifically, a resident with a history of acute embolism, thrombosis, atrial fibrillation, and chronic pulmonary edema reported shortness of breath and leg pain, expressing concern for a possible blood clot and requesting to be sent to the hospital. The assigned RN did not assess the resident or notify the physician, and did not facilitate the resident's transfer to the hospital. Instead, the RN left the resident's room after a verbal altercation and called the police, citing fear for personal safety. The police, upon arrival, called EMS, who then transported the resident to the hospital for evaluation and treatment. Other staff members, including a CNA and an LVN, were aware that the RN had not provided care or facilitated the resident's request for hospital transfer, but did not immediately report this potential neglect to the facility's Abuse Coordinator or Administrator. The Director of Nursing (DON) was not informed of the resident's request to go to the hospital or the RN's refusal to provide care until days later. The resident was admitted to the hospital with symptoms consistent with his medical history, including worsening lower extremity edema, pain, and dyspnea, and was treated for possible DVT and pulmonary embolism. The facility's policy required immediate reporting of suspected abuse or neglect to the Administrator and appropriate authorities. However, the failure of the RN to provide care and the failure of other staff to report the incident in a timely manner resulted in the RN continuing to work additional shifts after the incident. The deficiency was identified as Immediate Jeopardy due to the risk of serious harm to residents, as staff did not follow established procedures for reporting and responding to allegations of neglect.