Failure to Timely Report Fall with Injury and Alleged Neglect
Penalty
Summary
The facility failed to ensure timely reporting of alleged neglect and a fall with injury involving a resident with severe cognitive impairment and significant physical limitations. The resident, who required a two-person assist and mechanical lift for transfers due to dementia, stroke, and hemiplegia, experienced a fall while being transferred by a single CNA, contrary to her care plan. The fall resulted in a fractured right great toe and a laceration to the lip, with subsequent pain requiring medication and orthopedic referral. Following the incident, the resident's family member alleged neglect, expressing concern that such accidents should not occur under 24-hour facility care. The allegation was communicated to facility staff, but the incident and the neglect allegation were not reported to the State Survey Agency within the required timeframe. Facility policy and federal regulations mandate immediate reporting of such incidents, especially when they involve potential neglect or result in serious injury. However, the facility did not notify the State Survey Agency within two hours of the incident or within 24 hours for the neglect allegation, as required. Interviews with staff revealed confusion and inconsistency regarding the reporting requirements and the circumstances of the fall. The CNA involved admitted to performing a two-person assist transfer alone due to staffing shortages, acknowledging that this practice increased the risk of resident falls. Despite the family member's initial allegation of neglect, the administrator did not report the incident, citing the family member's later recantation. The facility's failure to report both the fall with injury and the neglect allegation constituted a deficiency in meeting regulatory requirements for timely reporting of suspected abuse, neglect, or injury.