Failure to Timely Report Allegation of Mistreatment Due to Inadequate Weekend/Holiday Procedures
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to ensure the timely reporting of suspected abuse, neglect, or mistreatment in accordance with federal and state requirements. Specifically, an allegation of mistreatment and neglect was reported by a resident's daughter via email to the Nursing Home Administrator (NHA) on a Sunday evening. The facility's policy requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediately, but not later than 2 hours if abuse or serious bodily injury is involved, or within 24 hours if not. However, the incident was not reported to the State Survey Agency until two days later, after the holiday weekend. The resident involved had significant medical conditions, including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage, polyneuropathy, morbid obesity, and chronic pain syndrome. The resident was cognitively intact, able to communicate effectively, and had no documented behavioral or depressive symptoms. The concern arose when the resident informed their daughter that an aide had stated an intention to take a picture of the resident's bowel movement, prompting the daughter to immediately notify the NHA via email. Despite the facility's established policy, the NHA did not review the email until after the holiday, resulting in a delay in reporting the allegation to the state agency. The NHA confirmed that there was no process in place for monitoring time-sensitive emails over weekends or holidays, and no other staff were assigned to scan for such communications. The delay in reporting was attributed to the NHA being the sole recipient and reviewer of these communications, and the lack of an alternative process for timely response during periods when the NHA was unavailable.