Failure to Report Allegation of Neglect Following Resident Fall and Injury
Penalty
Summary
The facility failed to report an allegation of neglect involving one resident, as required by its own policy and state regulations. The policy mandates immediate notification of the Administrator or Director of Nursing (DON) and subsequent reporting to the Pennsylvania Department of Health when incidents of abuse, neglect, exploitation, or mistreatment are alleged or suspected. Despite this, the facility did not submit a report of neglect to the state survey agency for the incident involving the resident. The resident in question had diagnoses including arthritis, Parkinson's disease, and depression, and was assessed as requiring assistance from two staff for transfers, with safety interventions such as bed and chair alarms and a low bed. The care plan also indicated the need for prompt response to requests for assistance and provision of a bedpan or bedside commode as needed. On the date of the incident, the resident was found self-transferring in the bathroom after requesting privacy, and subsequently fell, resulting in significant injuries including a right elbow dislocation, wrist fracture, and elbow fracture. Staff responded to another resident's alarm, leaving the resident unsupervised in the bathroom. The resident was later found on the floor, in pain, and required medical intervention including x-rays, orthopedic evaluation, and hospital treatment. Despite the severity of the incident and the facility's policy requirements, the event was not reported to the state as an allegation of neglect. The DON confirmed during interview that the facility failed to report the incident as required.