Failure to Report Allegations of Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report allegations of abuse or neglect to the State Survey Agency for two residents. For one resident with COPD, acute exacerbation, and respiratory failure, a physician order dated 11/4/25 directed administration of morphine sulfate 0.25 ml by mouth every hour as needed for shortness of breath and/or moderate to severe pain. A former staff member reported that on 11/6/25, an LPN assigned to this resident refused to administer the ordered pain medication despite other staff reporting the resident was screaming, short of breath, and very anxious. The former staff member stated the Administrator was aware of the incident and spoke with the LPN, but no Facility Reported Incident (FRI) was submitted. The Administrator later acknowledged there was no FRI submitted, and the LPN/Unit Manager also confirmed awareness of the incident and that no FRI was reported. For another resident admitted with a hip fracture and dementia, a former staff member reported being notified that an LPN forced the resident to remain in a wheelchair at the nurse’s station for most of the night and continuously gave the resident coffee because the LPN did not want to deal with the resident falling and any potential incident reports. The former staff member stated she informed the Administrator of this incident and was told not to submit an FRI because it was handled in-house. The DNS stated there should have been an investigation of this incident and clarified that while residents may be monitored at the nurse’s station, it should not be for the entire night or for staff convenience. The Administrator acknowledged there was no FRI submitted to the State Survey Agency for this incident.
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