Failure to Report Resident Injury During Transfer
Penalty
Summary
The facility failed to immediately inform a resident's representative and physician about an accident that resulted in an injury requiring medical attention. The incident involved a resident who, during an assisted transfer, hit her head on the armrest of a wheelchair. This incident went unreported initially, and the bruising was only identified after a family member noticed it and reported it to the staff. The resident, who has a diagnosis of dementia and is moderately impaired cognitively, required substantial assistance for transfers and was at low risk for falls according to a recent assessment. On the day of the incident, the resident was being transferred by a CNA who did not properly position the wheelchair before the transfer. The CNA held the resident with one hand and the wheelchair with the other, leading to the resident losing control and hitting her head. The CNA did not report the incident immediately as she did not observe any immediate bruising or injury. It was only after the family member's observation that the incident was reported, and an assessment was conducted. The Director of Nursing confirmed that the protocol for reporting such incidents was not followed, as the CNA failed to notify the facility about the incident on the day it occurred. The incident was only documented after the family member's report, and subsequent assessments, including an x-ray, were conducted. The facility's policy requires all accidents or incidents to be reported and investigated, but this protocol was not adhered to in this case.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. IMMEDIATE CORRECTIVE ACTION: Staff A was counseled by Director of Nursing and competency was completed regarding safe patient transfers and reporting of incidents on Resident #1 did not have any negative outcomes related to the alleged deficient practice. Staff B received 1:1 education from the Director of Nursing regarding proper notification of changes in condition to physician and resident's representative according to facility policy on. Nursing staff was in-serviced by the Director of Nursing regarding proper notification of changes in condition to physician and resident's representative according to facility policy on. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: Any resident in the facility have the potential to be affected by the alleged deficient practice. A facility wide audit was conducted on to identify any residents with change in condition without proper notification of physician and resident's representative. No issues were identified. SYSTEMATIC CHANGES: The Assistant Director of Nursing conducted ongoing in-services with nursing staff regarding safe transfers and proper notification of resident's representative and physician. The Director of Nursing/Designee will review all new incidents/changes in condition during the morning meeting to ensure proper notification of resident's representative and physician according to facility policy. MONITORING: The Director of Nursing/Designee will conduct daily rounds and chart review x 5 days, then weekly x 4 weeks, then random biweekly review, to ensure that physician and resident's representative are promptly notified of significant changes in condition. The Director of Nursing/Designee will report findings to the Quality Assurance committee monthly for 3 months to ensure substantial compliance is achieved and maintained.