Failure to Report and Investigate Alleged Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency and did not conduct an investigation as required. Specifically, a nurse aide reported via email to the Nursing Home Administrator that, at the start of a shift, a resident was found seated in a Geri chair with clothing, a Hoyer pad, and the chair itself saturated with urine. The Hoyer pad in use was not the correct size for the resident according to the care plan, and there was no documentation indicating the resident had been toileted or changed prior to the shift. This information was communicated to the facility administration, but there was no documented evidence that the incident was reported or investigated. Interviews with facility staff confirmed that the administration was not aware of any incontinence neglect related to the resident, and the personnel file for the nurse aide involved was not immediately available due to the Human Resources Director being out sick. Despite multiple requests for investigation, there was no response from administration, and no documentation was provided to show that the required reporting and investigation procedures were followed in response to the allegation of neglect.