Failure to Timely Report Allegations of Abuse, Neglect, or Exploitation
Penalty
Summary
The facility failed to ensure that all suspected violations involving abuse, neglect, exploitation, or mistreatment were reported to the state agency within the required timeframe for two residents. In the first case, a nurse performed CPR on a resident who had a documented Do Not Resuscitate (DNR) order, despite the resident's wishes and clear documentation in the medical record and care plan. Staff interviews revealed that the nurse initiated CPR, and another staff member attempted to inform the nurse of the resident's DNR status during the event. The incident was not reported to the state agency as required, and there was no facility-generated report regarding this allegation of neglect for the resident during the relevant period. In the second case, the facility failed to report multiple allegations of neglect made on behalf of another resident. The resident's representative communicated concerns about inadequate pain management, lack of response from nursing staff, and failure to recognize significant changes in the resident's condition through text messages and emails to the previous Administrator and DON. These communications included specific allegations of neglect, such as staff not responding to call bells, not addressing the resident's deteriorating condition, and improper attempts to collect a urine sample. Despite these repeated allegations, there was no evidence that the facility reported them to the state agency as required. Interviews with facility staff, including the current Administrator and DON, confirmed that the previous leadership did not recognize or act upon these allegations as reportable events. The facility's own policies required immediate reporting of such allegations, but these procedures were not followed. The lack of timely reporting of suspected abuse, neglect, or exploitation could place residents at risk by failing to ensure that allegations are properly investigated by the appropriate authorities.