Failure to Report Resident Fall and Potential Neglect
Penalty
Summary
The facility failed to report an incident involving a resident, identified as Resident #66, who fell out of bed during incontinence care. The care was being provided by one Certified Nursing Assistant (CNA) instead of the two-person assistance required by the resident's Comprehensive Care Plan. This incident was not reported to the New York State Department of Health as required by state law, despite the resident sustaining a skin tear and bruising. The facility's policy mandates reporting any accident or incident where negligence is suspected, but the Director of Nursing and the Administrator did not consider the incident reportable, as they believed the injury was not serious. Resident #66 had a history of dementia, congestive heart failure, and atrial fibrillation, with severely impaired cognition as documented in their Minimum Data Set Resident Assessment. The incident occurred when the CNA instructed the resident to roll back, but the resident rolled the wrong way and fell. Statements from staff indicated that the CNA may have been rough with the resident, and another staff member expressed concerns about the CNA's conduct. Despite these concerns, the incident was not escalated to the Department of Health, highlighting a failure to adhere to reporting protocols for potential neglect or mistreatment.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 F609 Corrective Action- To assure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator and to other officials in accordance with State law through established procedures. 1. As noted, the investigation regarding resident #66, dated 2/19/25, was made aware to the state DOH during survey 2/24/25 through 2/28/25. C.N.A. # 7, was educated/counseled on properly following the residents care plan. 2. All residents with alleged violations involving abuse, neglect, mistreatment, including injuries of unknown source and misappropriation of resident property have the potential to be affected by this deficient practice. A retrospective review of all residents who have had such incidents in the past 30 days will be created and reviewed to assure that proper notification took place (if necessary). 3. The facility’s “Accident/Incident Investigation and Prevention” and “Facility Incident/abuse investigation and reporting” policies will be reviewed and revised if necessary to assure compliance. All staff will be in-serviced on these policies and the NYSDOH reporting guidelines. The Director of Nursing/Designee will oversee all education for staff. 4. To prevent further deficiency in this practice, the Director of Nursing / Administrator will perform audits of 10 resident accident and incident investigations each month for the next 3 months and then as needed based on the audit findings. Audits will verify that the facility is appropriately reporting all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property are being reported immediately to the administrator of the facility and to other officials in accordance with State Law through established procedure. The administrator will monitor this process and will review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Director of Nursing will assume overall responsibility for the correction of F609.