Failure to Report Resident Falls and Injuries to State Agency
Penalty
Summary
The facility failed to report two unusual occurrences involving two residents to the state agency, as required. In the first case, a resident with severe cognitive impairment and high fall risk was involved in an incident where a CNA assisted the resident to the floor after the resident missed the wheelchair while attempting to sit. The resident later stated that a staff member pulled the wheelchair from underneath him, resulting in a fall, although he did not recall if it was accidental or intentional. Staff interviews confirmed the incident, and the Director of Nursing acknowledged that such an occurrence should have been reported as it was out of the ordinary. In the second case, a resident with quadriplegia and intact cognition fell from a mechanical lift during a two-person transfer. The resident reported pain in the elbow, hip, and head, and was sent to the hospital several days later for evaluation due to persistent pain. Hospital records confirmed the resident presented with post-traumatic pain and bruising. Staff interviews indicated that the mechanical lift incident was witnessed, and the resident was assessed and offered hospital transfer at the time, which was initially declined. Despite these incidents, the facility did not report either event to the state agency as required. The facility was unable to provide a policy for reportable events and relied solely on state guidelines. Staff interviews revealed uncertainty about what constituted a reportable event, and documentation confirmed that both incidents were not reported, despite resulting in avoidable falls and, in one case, hospital evaluation for injuries.