Failure to Report Allegations of Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to ensure that allegations of abuse and neglect were reported to the State Agency (SA) for two residents. One resident, who was cognitively intact and responsible for their own medical decisions, reported being left in the bathroom without a call light for approximately 30 minutes, being asked to perform tasks they could not do independently, and overhearing staff use inappropriate language. The resident also described an incident where a staff member threw a catheter bag across the room and did not provide timely assistance when requested. These concerns were documented in a grievance and confirmed during an interview, but were not reported to the SA as required by facility policy. Another resident, who had moderately impaired cognition and an activated Power of Attorney for Healthcare, reported that a staff member consistently failed to provide requested care, such as moving a garbage can or assisting with clothing and positioning. The resident described feeling that the staff member did not want to help and recounted an incident where they sustained a skin tear while attempting to change their own brief after being told by staff to do so independently. These grievances and statements were reviewed in the resident's medical record and through staff interviews, but the allegations were not reported to the SA. The facility's policy requires immediate review and reporting of incidents that fit the definitions of abuse or neglect to the Division of Quality Assurance/Office of Caregiver Quality. Despite this, the facility did not report the allegations for either resident, with the Nursing Home Administrator stating that the grievances were considered subjective and did not warrant reporting. This inaction resulted in a failure to comply with regulatory requirements for reporting suspected abuse and neglect.