Failure to Report Alleged Neglect After Resident Fall Resulting in Serious Injury
Penalty
Summary
The facility failed to report an allegation of neglect to the state survey agency after a resident experienced a significant fall resulting in serious injuries. The resident, who had multiple diagnoses including cerebral palsy, epilepsy, abnormal posture, torticollis, and scoliosis, was assessed as being at moderate risk for falls and required two staff members for repositioning and turning in bed, according to her care plan. However, during a bed bath, only one CNA was present and rolled the resident onto her side. The CNA briefly turned away to get more washcloths, during which time the resident rolled off the bed and fell to the floor. Following the fall, the resident experienced pain and difficulty breathing, and was found to have several fractured ribs, a hip fracture, a pulmonary embolism, and a small pneumothorax. The incident was documented in the nurse's notes and the resident was sent to the hospital for evaluation and treatment. The CNA involved acknowledged checking the kardex for some care needs but was unsure if she reviewed the bed mobility assistance requirement, and expressed remorse for the incident. Despite the severity of the injuries and the circumstances of the fall, the Nursing Home Administrator did not report the incident to the state survey agency. The decision not to report was based on advice from a Regional Nurse Consultant, who attributed the fall to a mattress issue rather than a reportable event. The administrator later acknowledged that the CNA's handling technique contributed to the fall, but maintained that the incident was not reported as neglect or abuse as required by facility policy.