Failure to Timely Investigate and Report Allegation of Neglect
Penalty
Summary
The facility failed to timely investigate and report an allegation of neglect involving a resident with severe cognitive impairment, dementia, aphasia, and major depressive disorder. The resident developed a fever in the early morning, and although the representative was notified and interventions were initiated, there was a five-hour delay between the initial assessment and the resident's transfer to the emergency room. The resident's representatives expressed concern about this delay to nurse management, which constituted an allegation of neglect according to state guidelines and facility policy. Despite these concerns being reported, the facility did not log an investigation regarding the allegation of neglect, nor did they report the incident to the State Hotline as required by both state regulations and their own policy. The Chief Nursing Officer and Director of Nursing acknowledged awareness of the concerns and conducted an internal review, but did not perceive the concerns as an allegation of neglect and did not report them, stating that reporting would only occur if the facility was found at fault after their investigation.