Failure to Timely Report Suspected Neglect After Resident Fall Resulting in Serious Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the state agency as required. Specifically, a resident with a history of repeated falls, cognitive impairment, and significant physical limitations was left unattended in the bathroom by a CNA who was unfamiliar with the resident's care needs and could not communicate effectively due to a language barrier. The resident, who was dependent on staff for all activities of daily living and identified as a fall risk, fell while left alone and sustained a fractured femur and hip. The incident occurred when the CNA, after assisting the resident to the toilet, left the resident alone at her request for privacy and notified another CNA to check on her. However, the second CNA did not receive this instruction, and the resident was left unsupervised for several minutes. The resident attempted to transfer herself and fell, resulting in serious injuries. The care plan for the resident specifically indicated that she should not be left unattended in the bathroom due to her fall risk and cognitive deficits. Additionally, the resident had a communication board care planned to assist with her language and cognitive barriers, but it was not present in her room at the time of the incident. Despite the severity of the injuries and the circumstances indicating neglect, the facility administrator did not report the incident to the state agency as required by regulation. The administrator also did not initiate a timely investigation or collect staff statements immediately following the event. Interviews with staff revealed inconsistencies in the account of the incident, and the administrator ultimately determined internally that the event did not meet the criteria for state reporting, despite regulatory requirements to report such incidents involving serious injury and potential neglect.