Failure to Timely Report Suspected Abuse and Neglect
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of suspected abuse, neglect, or theft, as required by section 1150B of the Act and state law. Specifically, the facility did not report two separate incidents involving possible neglect to the State Agency within the required timeframe. In the first case, a resident with moderate cognitive impairment and significant physical limitations experienced an unwitnessed fall resulting in a left humerus fracture. The incident was not reported to the State Agency as possible neglect, and no Misconduct Report was initiated, despite facility policy requiring immediate reporting of such events. In the second case, another resident with severe cognitive impairment and multiple comorbidities, including respiratory failure and emphysema, experienced a decline in respiratory status after testing positive for COVID-19. The resident developed new and worsening symptoms over several days, but the provider was not notified until the resident was found unresponsive and subsequently hospitalized. Following the hospitalization, the resident's POA filed a complaint alleging neglect due to insufficient monitoring and delayed intervention. This allegation was not reported to the State Agency, and no investigation or Misconduct Report was initiated. Interviews with facility leadership revealed confusion and lack of clarity regarding the responsibility and process for reporting such incidents. The Nursing Home Administrator and Director of Nursing provided inconsistent statements about which incidents should be reported and who was responsible for reporting. Both ultimately acknowledged that the incidents should have been reported to the State Agency prior to completing internal investigations, but this did not occur in either case.