Failure to Recognize, Assess, and Report Resident Neglect After Major Fall
Penalty
Summary
The facility failed to recognize and protect a resident's right to be free from neglect following a major injury sustained from an unwitnessed fall. The resident involved had severe cognitive impairment and was non-verbal, making her an unreliable reporter of the event. After the fall, staff did not thoroughly assess the resident, particularly neglecting to assess her lower extremities despite her showing signs of pain. The staff manually lifted and transferred the resident without using a mechanical lift, contrary to facility policy, and failed to document the incident accurately in the medical record. The resident was left in pain and in soiled clothing until the following shift, when a more thorough assessment revealed a significant injury requiring hospitalization and surgery. Multiple staff interviews revealed confusion and lack of adherence to facility protocols regarding post-fall assessment, documentation, and reporting. The nurse on duty did not complete a full assessment or pain evaluation, and failed to document the incident properly after striking out the initial note. Communication among staff was incomplete, with inaccurate information relayed to the resident's family and other staff members. The decision not to send the resident to the hospital was made without a thorough assessment, and staff expressed discomfort with this decision but did not escalate the issue appropriately. The facility also neglected to report the unwitnessed fall with significant injury to the State Survey Agency, as required by both facility policy and federal regulations. The administrator, who also served as the Abuse Prevention Coordinator and Grievance Officer, was unaware of the need to report such incidents and had not submitted any facility-reported incidents in the previous six months. Education on post-fall assessment and reporting was not provided to staff until several months after the incident, further indicating a lack of timely response to the deficiency.