Failure to Accurately Report and Classify Resident Fall as Potential Neglect
Penalty
Summary
The facility failed to accurately report and classify an incident involving a resident who sustained a fall from bed as a potential allegation of neglect. The incident occurred when the resident, who was dependent on staff for bathing, hygiene, rolling, and moving from lying to sitting, was left unattended in bed at its highest position while a nurse aide left the room to consult with a nurse about a wound bandage. The resident subsequently rolled out of bed and was found on the floor with injuries including a bruised eye and knee, requiring transfer to the emergency room for evaluation. Documentation and witness statements revealed inconsistencies in the facility's reporting to the State. The initial incident report incorrectly stated that the resident had enabler bars and that care plan interventions were followed. However, clinical records and staff interviews confirmed that no enabler bars were ever ordered or present, and that the resident was left alone in a high bed, contrary to safe care procedures. The nurse aide involved acknowledged leaving the resident unattended and received education on the risks associated with this action. Despite obtaining staff statements and providing education after the event, the facility did not report the incident as a potential neglect case to the appropriate authorities. The omission of critical details—such as the resident being left unattended in a high bed and the lack of enabler bars—resulted in the failure to accurately report the circumstances and potential neglect associated with the resident's fall and subsequent injury.