Failure to Report Resident Injury
Penalty
Summary
The facility failed to immediately inform the resident's representative and physician about an accident that resulted in an injury requiring medical attention for one resident. During an assisted transfer, the resident hit her arm on the wheelchair, and the incident went unreported until a family member identified and reported it to the staff. The resident was observed with a small discoloration under the right eye and scratches on both arms. The resident required substantial assistance for chair/bed-to-chair transfers and had a care plan indicating a risk for falls related to mobility. Despite this, the Certified Nursing Assistant (CNA) did not properly position the wheelchair before transferring the resident, leading to the incident. The CNA failed to report the incident to the nurse, which was a breach of protocol. The Director of Nursing (DON) confirmed that the protocol required staff to report such incidents to the doctor and family, complete an incident report, and document the occurrence. However, there was no documentation related to the incident in the progress notes, and the CNA was reprimanded for not reporting the incident. The facility's policy required all accidents or incidents to be investigated and reported, but this 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.