Failure to Timely Report and Document Resident Fall
Penalty
Summary
The facility failed to ensure timely reporting and documentation of an allegation of neglect involving a cognitively impaired resident with moderate intellectual disabilities and schizoaffective disorder, who required maximum assistance for activities of daily living. Multiple staff members witnessed or were informed of the resident falling out of bed and hitting their head, but did not follow established procedures for reporting and responding to such incidents. Staff B and Staff C both observed or were aware of the fall, but were instructed by Staff E, an Attendant Counselor Manager, not to complete an incident report, despite facility policy requiring incident reporting and nurse assessment before moving the resident. Staff B and Staff C did not escalate their concerns or report the incident further, citing fear of reprisal and uncertainty about the process. Staff E, upon being informed of the resident being on the floor, did not believe the incident was reportable and did not ensure a nurse assessment or incident report was completed. Staff D, another manager, was later informed of the incident but also did not report it to higher authorities. Review of facility records confirmed there was no documentation or incident report regarding the resident's fall and head injury during the relevant period. This lack of timely reporting and documentation resulted in a failure to notify proper authorities and ensure appropriate follow-up for the resident.