Failure to Report Major Injury and Implement Abuse Reporting Policy
Penalty
Summary
The facility failed to develop and implement abuse reporting policies as required, specifically in the case of one resident who experienced a significant injury. The resident, a male with multiple medical conditions including legal blindness, morbid obesity, and a history of fractures, fell out of a shower chair while being transported back to his room after a shower. The incident resulted in a right femur fracture, and the resident was subsequently hospitalized. Documentation indicated that the shower chair's wheels malfunctioned, contributing to the fall, and the resident reported hearing a loud pop and experiencing immediate pain and inability to bear weight. Despite the severity of the injury, the facility did not report the incident to the State Agency as required by their abuse prohibition policy. Interviews with staff revealed confusion and lack of clarity regarding what constitutes a reportable event, with some staff believing that any fracture should be reported, while others deferred to internal investigations that ruled out abuse or neglect. The incident was not reported within the required two-hour window, and the facility's abuse coordinator and administration determined in-house that the event was not suspicious and did not meet their criteria for neglect or abuse, despite the major injury. Further review showed that the facility's policy required reporting all allegations and substantiated occurrences of abuse, neglect, or misappropriation, especially those resulting in serious bodily injury, to the state agency immediately or within two hours. However, the incident involving the resident's fall and fracture was not reported as mandated. The lack of reporting was confirmed through interviews and record reviews, and a complaint was later filed by the resident alleging neglect due to the injury.