Failure to Report Alleged Neglect Following Resident Fall
Penalty
Summary
The facility failed to report an alleged violation of potential neglect involving a resident with chronic obstructive pulmonary disease, intellectual disabilities, and lumbago sciatica. The resident, who had some memory impairment and required assistance of two staff for transfers and was totally dependent for bed mobility, was found lying on the floor beside the bed with a bruise on the right shin and bleeding from the right second toenail. Facility documentation indicated that only one nurse aide was present during the incident, despite the care plan requiring two staff for bed mobility. The aide reported that the resident slid from the bed to the floor while being turned. There was no documented evidence that the facility reported this incident of alleged neglect to the appropriate state and local agencies as required by facility policy. The Director of Nursing confirmed in an interview that the incident was not reported to the authorities, which is a violation of both facility policy and state regulations.