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Based on interview, record review, and review of the facility policy it was determined the facility failed to ensure an allegation of neglect was reported in accordance with applicable local, state, or federal law for one (1) of ten (10) sampled patients (Patient #1). Interviews with facility staff revealed on 05/17/15, Patient #1 was observed to have "dried" stool on his/her left thigh and buttock area, was "crying," and stated, "I've been telling them I need to use the bathroom." Continued interviews revealed Sitter #1, which had been assigned to provide visual supervision and alert staff of the patient's needs, was observed to be in a chair, covered with a blanket, and was "asleep." Interviews revealed the sitter was immediately removed from patient care, the patient was assessed, and care needs were provided. However, administrative staff failed to report the allegation of neglect to state agencies as required.

The findings include:

Review of the facility policy titled "Suspected Child/Adult Neglect/Abuse," dated 08/02/13, revealed facility staff was to identify victims of alleged or suspected abuse or neglect, and was to notify and release information to the proper authorities as legally required in accordance with state law.

Review of the medical record for Patient #1 revealed the facility admitted the patient on 05/15/15 with diagnoses that included a history of mental illness and confusion. Facility staff assessed the patient to require a sitter for "confusion" on 05/15/15.

Interview with Registered Nurse (RN) #2 on 09/01/15 at 12:10 PM revealed she observed Patient #1 on 05/17/15 at approximately 11:30 AM to be visibly upset, "crying," and stating, "I need to use the bathroom." RN #2 stated the patient had "dried feces on" him/her. RN #2 stated the sitter, which had been assigned to supervise the patient, was in a chair, covered up to her shoulders with a blanket, and appeared to be asleep. The RN stated the incident was immediately reported to her supervisor.

Interview with RN #1 on 09/01/15 at 12:40 PM revealed she observed Patient #1 on 05/17/15 at approximately 11:30 AM to be tearful, "crying," and was stating, "I've been telling them I need to go to the bathroom." RN #1 stated the patient had "dried" stool on his/her left thigh and buttock area. Continued interview revealed the sitter, which had been assigned to provide supervision to the patient, was in a chair at the patient's bedside, covered with a blanket, with her eyes closed, and appeared to be asleep. The RN stated she was "very angry and upset" to observe a patient in this condition, when the sitter was responsible to observe and alert nursing staff of Patient #1's needs. RN #1 stated she had suspected neglect and immediately reported the incident to her supervisor.

Interview with RN #3 on 09/01/15 at 11:55 AM revealed she had been notified on 05/17/15, by RN #1 and RN #2, that Patient #1 had been observed to have dried stool on him/her, and that the sitter assigned to provide supervision to the patient was asleep at the patient's bedside. The RN stated she reported the incident to her supervisor, the Interim Chief Nursing Officer (CNO).

Interview with the CNO on 09/01/15 at 2:30 PM revealed she acknowledged an allegation of neglect had been reported to her, concerning Patient #1, on 05/17/15. She stated she ensured the patient's needs were immediately met, the alleged perpetrator was immediately removed from patient care, and an investigation was conducted; but she did not report the allegation of neglect to state agencies as required.