Failure to Report Possible Neglect of a Resident
Penalty
Summary
The facility failed to implement its policies and procedures for reporting possible neglect of a resident. According to facility policy, any suspicion of abuse, neglect, exploitation, or misappropriation must be reported immediately to designated authorities, including the state licensing agency, ombudsman, resident's representative, adult protective services, law enforcement, the resident's attending physician, and the facility medical director. Immediate reporting is defined as within two hours for allegations involving abuse or serious bodily injury, or within 24 hours for other allegations. In this case, documentation and staff interviews revealed that a resident with dementia, a history of stroke, and moderate cognitive impairment was not provided with incontinence care for multiple days, despite being always incontinent of bowel and bladder as documented in the care plan and MDS assessment. Therapy staff observed the resident to be extremely soiled on consecutive days, with soiled clothing and bedding, and reported these findings to the nurse supervisor, Administrator, Director of Rehabilitation, Social Services, and Human Resources. However, the facility failed to submit a report of possible neglect to the State Survey Agency as required by policy. The Nursing Home Administrator later confirmed that the facility did not implement the required reporting procedures for this incident involving possible neglect.