Failure to Timely Report Suspected Neglect Following Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to report an alleged violation involving neglect within the required 24-hour timeframe. Specifically, a resident with multiple complex medical conditions, including type 2 diabetes mellitus, right femur fracture, hemiplegia, and respiratory failure, sustained a fall from a Hoyer lift during a one-person assisted transfer. The incident resulted in a fracture, and the event was documented by the Interdisciplinary Team as a fall from the lift. However, the State Survey Agency (SSA) was not notified of the incident until approximately seven days after it occurred, and there was no documentation indicating that Adult Protective Services (APS) had been notified at all. During an interview, the Director of Nursing (DON) acknowledged the regulatory requirement to report suspected abuse or neglect to the state within two hours and confirmed that the facility did not investigate the incident for possible neglect in a timely manner. The DON also stated that APS was not notified and could not provide a reason for this omission. The failure to report the incident as required and to notify the appropriate authorities constituted a violation of mandated reporting protocols.