Failure to Timely Report Serious Resident Injuries from Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure timely reporting of alleged violations involving abuse, exploitation, or mistreatment, specifically in cases where residents sustained serious injuries during transfers with a mechanical lift. According to the facility's own policy and state regulations, such incidents must be reported to the appropriate authorities within two hours if they involve abuse or result in serious bodily injury. However, in two separate cases, the facility did not meet these reporting requirements. In the first case, a resident with diagnoses including heart failure and anxiety, and who required dependent assistance for transfers, fell during a mechanical lift transfer and sustained a left humerus fracture. The incident occurred in the early afternoon, but the injury was not reported to the New York State Department of Health until nearly three days later, after the Regional Director of Nursing reviewed the hospital discharge summary and realized the extent of the injury. Both the Regional Director of Nursing and the Associate Administrator acknowledged awareness of the reporting requirements but could not provide a reason for the delay. In the second case, another resident with severe cognitive impairment and total dependence on staff for activities of daily living fell during a mechanical lift transfer and sustained a right femur fracture. The incident was identified in the early afternoon, and x-ray results confirming the fracture were available later that evening. Despite this, the report to the Department of Health was not submitted until the following morning, more than eight hours after the injury was confirmed. Interviews with nursing and administrative staff revealed uncertainty about reporting responsibilities and a lack of timely action once the injury was identified.