Failure to Report and Investigate Alleged Neglect Following Change in Resident Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely reporting and investigation of an allegation of neglect for one resident. The resident's representative reported concerns to staff regarding the resident's lethargy, pain, and delayed medication administration. The representative was unable to locate the assigned nurse for over an hour, and when the nurse was found, she was dismissive of the concerns. The representative explicitly told the Nursing Home Administrator (NHA) that he believed the resident was neglected, but did not receive any follow-up from the facility. Medical record review revealed that the resident, who had a complex medical history including end-stage renal disease, lupus, and chronic kidney disease, experienced a change in condition with increased lethargy and pain. Despite these changes and abnormal laboratory results, there was no documentation that a change of condition assessment was completed or that a provider was notified. Medications were administered late throughout the day, and staff interviews confirmed that the nurse assigned to the resident was repeatedly absent from the unit for extended periods without proper coverage. The facility's own policy required immediate reporting and investigation of alleged neglect, but the incident was not documented in the facility's reportable log, and there was no evidence that the required notifications or investigations were completed. Interviews with the DON and Regional Nurse Consultant confirmed that the expected procedures for assessment and provider notification were not followed. The NHA acknowledged that the nurse's actions could constitute neglect but did not ensure the incident was reported as required.