Failure to Timely Report Allegation of Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of neglect to the state agency within the required 24-hour timeframe. A cognitively intact female resident with hemiplegia and hemiparesis following a stroke, who was totally dependent on staff for toileting and frequently bowel incontinent, reported that on a specific evening she requested assistance for incontinence care after receiving a laxative and experiencing diarrhea. She stated that a CNA responded to her call light, said she needed to gather supplies, and then did not return. The resident reported that when she activated the call light again, the CNA told her she only had to change the resident every two hours, refused to change her brief or provide her name, and stuck her tongue out and rolled her eyes before leaving the room. The resident stated she remained sitting in fecal matter for over an hour, felt she was not being treated like a human being, and became afraid to press her call light because she did not trust anyone to help her. Her family member, who had been present earlier that evening, corroborated that the resident had requested to be changed and that the CNA initially responded but did not return before the family member left the building. The family member later received a distressed call from the resident reporting she still had not been changed and that the CNA had refused to assist her and had behaved disrespectfully. The family member then returned to the facility, confronted the CNA, and reported the allegations to the Administrator. The CNA later stated she was new to the facility, acknowledged being informed that the resident needed to be changed, and reported that she changed the resident once shortly after being notified and again 35–40 minutes later, denying any disrespectful behavior. The Administrator stated he was notified by the family member that evening that the resident had several large bowel movements and had not been changed for two hours, and the resident reported to him that the CNA had turned off the call light, said she would return, and then stuck her tongue out and rolled her eyes. The Administrator determined the situation was more related to customer service than neglect, believed neglect required harm or injury, and therefore did not report the allegation to the state agency within 24 hours, despite facility policy defining neglect as failure to provide necessary goods and services that are necessary to avoid physical harm, pain, mental anguish, or emotional distress and requiring that all allegations of abuse and neglect be reported to outside agencies within applicable timeframes.
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