Failure to Timely Report Allegation of Potential Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of potential neglect to the State Agency within required timeframes. Facility policy on Abuse, Neglect and Exploitation, revised 1/2024, requires that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property be reported immediately, but not later than 2 hours if abuse or serious bodily injury is involved, or within 24 hours if not, to the administrator and appropriate officials including the State Survey Agency. The policy also requires that results of all investigations be reported to the administrator and State Survey Agency within 5 working days. The Grievance Policy similarly directs that upon receipt of a grievance, the Grievance Official determine if it is reportable and, consistent with the Abuse Prevention Policy, immediately report all alleged violations involving neglect or abuse to the administrator and as required by state law. Resident 1 was admitted with hemiplegia and hemiparesis following a stroke and was frequently incontinent of bladder, with intact cognition as evidenced by a BIMS score of 13. A grievance form dated 02/27/2026 documented that a family member reported the resident had stayed wet for over four hours and that when assistance was requested, the request was ignored, requiring the family member to find different staff to assist. This grievance was heard by the facility social worker. Review of the facility’s Reportable Incident Log for the relevant period showed no reportable incident involving this resident, indicating that the allegation was not entered as a reportable event. During interviews, the resident reported having to wait for assistance after activating the call light, sometimes resulting in incontinence in the brief, with the longest wait being approximately 45 minutes. Another family member reported an instance of waiting up to four hours for a call light to be answered, though the date was unknown. The DON stated that an investigation into the grievance was conducted but not documented and confirmed that the grievance related to the resident was an allegation of potential neglect that should have been reported to the State Agency within required timeframes. The administrator acknowledged that the allegation of potential neglect was not reported, explaining that they believed a report was not required if there was no resident outcome. This sequence of events led to the failure to report the allegation of potential neglect as required by facility policy and licensure regulations.
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