Failure to Report Alleged Neglect and Inadequate Resident Care
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident who was moderately cognitively impaired and completely dependent on staff for all activities of daily living, including personal hygiene, eating, toileting, and mobility. The resident's Power of Attorney (POA) reported that the resident often waited 30-60 minutes for staff to respond to call lights and that personal cameras in the resident's room showed staff not entering for multiple hours. On the date of the incident, two CNAs used a mechanical lift with a toilet sling to transfer the resident, during which the resident was improperly positioned, experienced pain, and was left exposed and distressed. The POA witnessed the resident being forced to have a bowel movement in a garbage can while screaming in pain, and the CNAs refused to reposition the resident or provide further care, leaving the resident soiled and uncomfortably positioned in bed. The POA and private caregivers reported that they were required to provide most of the resident's care, including repositioning, feeding, administering medications, and hygiene, due to staff neglect. The POA communicated these concerns, including the specific incident, to the Interim DON via email and requested that the involved CNAs not provide further care to the resident. Despite these communications, the CNAs continued to care for the resident, and the DON responded that they were not the resident's primary CNAs, so it was acceptable. The POA was told by the DON that no one else could address the ongoing care concerns. The Administrator in Training (AIT) acknowledged being made aware of the family's concerns but stated that the Interim DON was handling the situation and did not escalate the issue or report it as a grievance. The facility did not report the allegation of neglect to the State Surveying Agency as required by their abuse prevention policy, which mandates immediate reporting of abuse or neglect allegations. Both the AIT and Interim DON confirmed that the incident was not reported, and the facility did not follow its own abuse policy.