Failure to Timely Report Suspected Neglect Following Resident Injury During Transfer
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency within the required timeframe after a resident sustained an injury during a transfer. According to facility policy, all alleged violations involving neglect must be reported immediately, but not later than two hours if serious bodily injury is involved, or within 24 hours if not. In this case, a resident with severe cognitive impairment, dependent on staff for transfers, was transferred from a wheelchair to bed by two CNAs who did not verify the required method of transfer. The resident, who required a Hoyer lift with two staff assist per her care plan, was instead transferred using a draw sheet, resulting in her yelling out in pain and later being diagnosed with a fractured left humerus. Interviews with the CNAs involved revealed that neither was familiar with the resident's specific transfer needs and neither checked the care plan or system to confirm the appropriate transfer method prior to the incident. Both CNAs acknowledged that they should have verified the resident's transfer requirements. The Director of Nursing (DON) and Administrator were notified of the incident on the day it occurred, and an internal investigation determined that the injury resulted from improper transfer technique, which was not in accordance with the resident's care plan. Despite these findings, the Administrator did not report the incident to the State Survey Agency, as required by facility policy and regulation. Both the DON and Administrator stated they did not initially consider the incident to be neglect, viewing it instead as a mistake. As a result, the required notification to the State Survey Agency was not made, constituting a failure to report suspected neglect in a timely manner.