Failure to Timely Report Suspected Neglect and Injury of Unknown Origin
Penalty
Summary
A resident with Parkinson's Disease and a history of myocardial infarction was assessed to require an EZ stand and assist of one for transfers, as documented in the care plan. Despite this, the resident was transferred using a pivot transfer by a single staff member, contrary to the care plan instructions. Following this transfer, the resident complained of pain, swelling, and bruising to the left knee, which she reported began after being transferred without the EZ stand. The resident's condition declined both physically and cognitively after the incident, and she subsequently passed away at the facility. The facility's own policy requires immediate reporting of any suspected abuse, neglect, or injury of unknown origin to the Nursing Home Administrator and the State Agency, with specific timelines for reporting based on the severity of the injury. Despite multiple staff being aware of the resident's complaints, bruising, and decline, the incident was not reported to the administrator or the State Agency within the required timeframe. The responsible party for the resident expressed concerns to the facility, believing the resident had been dropped during the transfer, but these concerns were not communicated to the appropriate authorities as required. Interviews and record reviews revealed that the facility did not initiate a Facility Reported Incident (FRI) related to the transfer without the EZ stand, nor did they notify the State Agency. The Nursing Home Administrator stated that the incident was not reported because the facility followed an abuse reporting algorithm that did not consider the event as meeting the criteria for willful intent. However, surveyors noted that the algorithm used was not appropriate for skilled nursing facilities. The medical examiner's preliminary autopsy results indicated the cause of death was a fracture of the distal left femur, consistent with a fall or drop, further highlighting the failure to report the incident as required by policy and regulation.