Failure to Report Alleged Neglect and Follow Care Plan for Dependent Resident
Penalty
Summary
The facility failed to report an alleged violation of potential neglect to the appropriate state and local authorities as required by its abuse prohibition policy. The policy, last reviewed February 24, 2025, stated that the facility prohibited abuse, mistreatment, neglect, and exploitation for all residents and required immediate reporting of incidents, investigations, and the facility's response upon receiving information concerning suspected neglect or abuse. The policy also specified that a designee was to report allegations involving neglect to the appropriate state and local authorities. There was no documented evidence that this reporting occurred for the incident involving one resident. The resident involved had diagnoses including chronic respiratory failure with hypoxia, heart failure, and venous insufficiency, had no cognitive impairment, and was dependent for ADLs such as bed mobility, transfers, and toileting. The care plan identified an ADL self-care deficit and required assistance of two to three staff and use of a bed pad for bed mobility. On review of facility documentation, a nurse aide observed a bruise on the resident's left forearm while providing care, and further investigation showed that another nurse aide had used the resident's left forearm to roll the resident toward him, resulting in a small bruise. There was no evidence that a second staff member was present or that a bed pad was used as required by the care plan, and the DON acknowledged that the facility failed to report this incident of alleged neglect to the appropriate state and local agencies.
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