Failure to Investigate and Timely Report Alleged Neglect Related to Delayed Colostomy Care
Penalty
Summary
The facility failed to investigate and report within required timeframes an allegation of neglect related to untimely care and services for one cognitively intact resident. The resident had multiple diagnoses including necrotizing fasciitis, type 2 diabetes mellitus, chronic combined systolic and diastolic heart failure, difficulty in walking, muscle weakness, and colostomy status. The resident’s care plan documented a colostomy with daily and PRN ostomy care and extensive assistance needs for ADLs and bed mobility. The facility’s ANEMMI policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and required reporting of suspected events to state agencies within specified timeframes. On the date in question, the resident filed two grievances. The first grievance, received and dated with the same incident date, documented that the resident “waited too long for call light to be answered” and was investigated and resolved by the ADON the following day. The second grievance, also received and dated with the same incident date, documented a concern about customer service and was likewise marked as investigated and resolved the next day. However, the grievance documentation did not include a resident interview or resident statement for either grievance, and there was no indication that the allegation was treated as a potential neglect incident requiring ANEMMI investigation and external reporting. During interview, the resident reported that his colostomy bag broke during the 3p–11p shift, around 9 p.m., resulting in feces on his stomach and concerns about his wound, and that it took approximately three hours for staff to respond to his call light and complete the colostomy care around 11 p.m. He stated staff repeatedly told him they would get to it, and that he filed the grievance because of the delay and his concern about the integrity of his wound. He also reported that no one came and talked to him about the grievance related to the call light and colostomy issue, although the administrator did speak with him and his POA about the separate phone call complaint. The DON, who was the Abuse Coordinator, stated she viewed the grievance as a customer service issue, did not know how long the resident had waited, confirmed no resident interview was attached to the grievance investigation, and acknowledged that a three-hour wait for a call light response would be a problem. The DON later stated they were going to file a neglect report for this event, indicating it had not been reported within the required 24-hour timeframe.
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