Failure to Timely Report Allegation of Neglect Related to Resident Death
Penalty
Summary
The facility failed to timely report an allegation of neglect that involved a resident who later died. Facility policy N-1265, effective 11/30/2014 and revised 11/16/2022, states that once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to the proper officials in accordance with Federal and State regulations. According to the facility’s investigation, on 12/26/25 at approximately 8:03 p.m., during a phone conversation with the DON and the Administrator, the resident’s representative stated that he felt the resident should have been transferred to the hospital sooner. The investigation documented that the Administrator became aware of this concern at that time. The DON reported that the resident had been transferred to the hospital on a prior date and that the resident’s representative informed her on the morning of 12/26/25 that the resident had passed away. Later that day, the representative began asking more questions about what had occurred at the facility before the transfer and, during a three-way call with the DON and Administrator, expressed that the resident should have been sent to the hospital sooner. The DON stated she considered this an allegation of neglect. However, the allegation was not reported to the Agency until 12/27/25 at 3:29 p.m., and the DON acknowledged this delay, explaining that she and the Administrator were trying to gather more information and determine if there was anything to add to the report before submitting it.
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