Failure to Report Suspected Neglect After Resident Fall from Mechanical Lift
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency after a resident experienced a fall from a mechanical lift. The resident, who had diagnoses including dementia with behavioral disturbance, back pain, chronic pain, and spinal stenosis, was care planned to be transferred using a ceiling lift with a toileting sling for toileting and a full body split leg sling for all other transfers. On the date of the incident, staff transferred the resident from the wheelchair to the bed using a toileting sling, contrary to the care plan, and the resident fell out of the sling and hit her head. The nursing assistant involved stated the resident, who was confused and tired, placed her arms inside the sling during the transfer, despite being instructed to keep them outside. The ceiling lift representative confirmed that the toileting sling required the resident to keep their arms outside and that the sling may not have been appropriate for someone with cognitive or physical limitations. Despite the incident, the administrator and DON did not report the event to the state agency, stating that the care plan had been followed, even though documentation and interviews indicated otherwise. Facility policy required all suspected abuse or neglect, defined as failure to provide necessary goods and services to avoid harm, to be reported to the state agency within two hours of suspicion. The failure to report the incident as required constituted a deficiency in timely reporting of suspected neglect.