Failure to Timely Report Resident Injury to State Authorities
Penalty
Summary
The facility failed to report an alleged violation involving a resident's injury to the state department of health in a timely manner. A resident with multiple complex medical diagnoses, including Parkinson's disease, dementia, and muscle weakness, experienced an incident during a transfer using a sit-to-stand machine. Initial nurse's notes indicated the resident felt weakness in her legs and was unable to hold on to the machine, leading staff to return her to bed. At the time, no injuries were noted, and the incident was not documented until approximately nine hours later. Later that evening, the resident reported pain and swelling in her right shoulder and arm, prompting the nurse to contact the physician, who ordered a stat X-ray. The following day, the X-ray revealed a fractured neck of the humerus, and the resident was sent to the emergency room for further evaluation. Despite being made aware of the fracture, facility leadership did not file a Facility Reported Incident (FRI) as required by policy, which mandates immediate reporting to the state agency within two hours for serious bodily injury. Interviews with the DON confirmed awareness of the injury and the connection to the previous day's incident with the sit-to-stand machine. However, the DON had not yet interviewed the two aides involved in the transfer, and the nurse's notes and incident report were not completed by those present at the time of the event. Facility records showed no FRI was filed for the incident, and the internal investigation was incomplete at the time of the survey.