Failure to Timely Report Serious Resident Injury Following Fall
Penalty
Summary
The facility failed to immediately report an incident involving a resident who experienced a witnessed fall resulting in multiple serious injuries, including rib fractures, a cervical spine fracture, a thoracic compression fracture, and a scalp laceration. The fall occurred while the resident, who had a history of heart failure, osteoporosis, depression, mild cognitive impairment, and required substantial to maximal assistance with transfers, was being assisted by a CNA. The CNA did not use a gait belt and was not physically assisting the resident during the transfer, contrary to the resident's care plan and functional assessment, which indicated the need for moderate assistance. Following the fall, the resident was transported to the hospital, where her injuries were confirmed. Despite the severity of the injuries and the witnessed nature of the fall, the facility did not report the incident to the State Agency within the required two-hour timeframe. The DON and nurse supervisor did not initially recognize the incident as potential neglect or abuse, and the extent of the resident's injuries was not known to the facility until hospital records were received upon the resident's re-admittance. The facility's investigation did not include obtaining hospital records at the time of the incident, and the CNA involved was not suspended or restricted from resident care immediately following the event. Interviews with staff revealed a lack of clarity regarding reporting requirements and the appropriate response to such incidents. The nurse supervisor viewed the event as a failure in transfer technique rather than a potential case of neglect, and the DON was unaware of the need to report the injuries to the State Agency. The facility's policies required immediate reporting of suspected abuse, neglect, or misappropriation of resident property, but these procedures were not followed in this case.