Failure to Timely Report Alleged Neglect and Injuries
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or injuries of unknown source were reported immediately, but not later than two hours after the allegation was made, as required by regulation. Specifically, the facility did not report a family member's (FM) concern regarding the care of a resident who had experienced multiple falls and a change in condition. The FM expressed concerns to facility staff about the resident's care, including the timeliness of response to a possible stroke and the presence of additional rib fractures identified at the hospital. Despite these concerns being communicated to the social worker, assistant director of nursing (ADON), and later to the director of nursing (DON) and administrator, the facility did not report the allegations to the State Survey Agency or initiate an investigation as required by their own policy and federal regulations. The resident in question was an elderly male with severe cognitive impairment, a history of falls, and multiple comorbidities including atrial fibrillation, renal insufficiency, urinary tract infection, diabetes, cerebrovascular accident, malnutrition, and muscle weakness. He was dependent on staff for most activities of daily living and had experienced two falls with injury (not major) since admission. On the day of the incident, the resident exhibited right-sided weakness and difficulty feeding himself, prompting the nurse to notify the physician and arrange for hospital transfer for possible stroke evaluation. The FM later reported to staff that the hospital had found additional rib fractures, raising concerns about the adequacy of care and fall prevention in the facility. Interviews with facility staff revealed that the FM's complaints were communicated internally but not reported externally as required. The DON and administrator both stated that they did not believe the situation constituted neglect or required reporting, and no investigation was initiated. The facility's abuse and neglect policy mandates immediate reporting of all allegations to the administrator and appropriate agencies, but this protocol was not followed in this case. The failure to report and investigate the FM's concerns about the resident's care and injuries constituted a deficiency in the facility's compliance with abuse and neglect reporting requirements.