Failure to Timely Report Allegation of Neglect to State Authorities
Penalty
Summary
The facility failed to report an allegation of neglect within 24 hours to the local state field office for one of two residents. Facility policy dated 7/1/25 on Abuse, Neglect, and Exploitation required that all alleged violations be reported to the Administrator, state agency, adult protective services, and other required agencies immediately but no later than two hours if the allegation involved abuse or serious bodily injury, or no later than 24 hours if it did not. Neglect was defined in the policy as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of clinical records showed that one resident, admitted and later readmitted with diagnoses including constipation, hypertension, and cervicalgia, was involved in the incident. Progress notes for this resident dated 2/12/26, entered by RN Employee E1, documented that the resident requested to go to the hospital for abdominal pain and constipation and ultimately called 911 personally. Information later submitted to the State Agency by the DON on 2/16/26 indicated that on 2/13/26 the resident had requested transfer to the hospital, and an LPN and NA reported this request to the RN Supervisor, Employee E1. The RN Supervisor allegedly refused to assess the resident and refused to send the resident to the hospital. This sequence of events constituted an allegation of neglect that, per policy, required reporting within 24 hours to the appropriate agencies, including the local state field office. Interviews with the DON and the Nursing Home Administrator on 2/25/26 confirmed that such allegations must be reported within 24 hours and that the facility did not meet this requirement for this resident, resulting in noncompliance with multiple cited state regulations.
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