Failure to Report and Investigate Injury Following Incorrect Transfer
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of abuse, neglect, or injuries of unknown origin for a resident who experienced significant harm following an incorrect transfer. The resident, who had Parkinson's Disease and required an EZ stand with one-person assist for transfers, reported severe left knee pain after being transferred by a method not consistent with her care plan. The pain began after a pivot transfer was performed instead of using the required EZ stand, and the resident subsequently developed bruising, swelling, and was later found to have a left distal femur fracture. Despite the resident's complaints and the visible signs of injury, the facility did not report the incident to the Nursing Home Administrator or the State Agency as required by their abuse prevention policy. The facility's own policy mandates immediate reporting of any suspicion of abuse or serious bodily injury, including injuries resulting from failure to follow the care plan. However, the incident was not entered into the facility's grievance log or reported as a Facility Reported Incident (FRI) to the state, even though several staff members were aware of the situation soon after it occurred. Interviews with facility leadership revealed that the decision not to report was based on an abuse reporting algorithm intended for assisted living facilities, not skilled nursing facilities. The administration did not consider the incident to meet the criteria for willful intent, despite the resident's injury and subsequent death. The facility's investigation was delayed, and conflicting accounts from staff and the resident were cited as reasons for not reporting. The failure to follow the resident's care plan and the lack of timely reporting to the appropriate authorities constituted a violation of the facility's abuse prevention and reporting policies.