Failure to Report Suspected Neglect Incident
Penalty
Summary
The facility failed to report an incident of neglect to the State Survey Agency as required by its own policy and federal regulations. A resident with a history of anxiety disorder and severe expressive aphasia, who was dependent on staff for toileting, was found left on a bedside commode for an extended period of time. The care plan for this resident specified the need to ensure the call light was secured and within reach during toileting due to impaired communication. A progress note documented that the resident was found with blanchable redness to both buttocks, a light purple area on the right buttock, and a bruise on the left wrist, which was attributed to the resident banging on the wall for assistance. The resident denied pain and showed no signs or symptoms of pain at the time of assessment. Despite these findings, the facility did not report the incident to the State Survey Agency as required by their policy, which mandates immediate reporting of all alleged violations of abuse or neglect. An administrative nurse confirmed during an interview that the incident was not reported. The failure to report this incident constitutes a deficiency in the facility's compliance with abuse and neglect reporting requirements.