Failure to Timely Report Alleged Neglect Following Resident Injury
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency for one resident who required extensive assistance for bed mobility and was dependent for toileting hygiene. During peri-care provided by a CNA, the resident, who had hemiplegia and other significant medical conditions, was left unattended when the CNA left the bedside to obtain additional supplies. While unattended, the resident attempted to reach for an item on her bedside table and rolled off the bed. The CNA found the resident on the floor after hearing her scream and notified the nurse, who performed an assessment and found no immediate injuries or abnormal vital signs at that time. Subsequent documentation indicated that the resident was monitored with neuro checks and was stable until the following day, when she was found to be lethargic and only responsive to painful stimuli. The resident was then sent to the hospital for evaluation, where imaging revealed a fracture of the left femur near the knee. The facility's Director of Nursing and Administrator were uncertain about the timing and location of the injury, as the x-ray did not specify the age of the fracture, and there were conflicting accounts regarding whether the injury occurred at the facility or the hospital. Despite the incident and the resident's significant change in condition, the facility did not report the allegation of neglect to the state agency as required by their own policy, which mandates reporting all alleged violations within specified timeframes. Interviews with facility leadership confirmed that the event was not reported because they did not initially consider it a fall or neglect, and there was confusion about the details of the incident and the resulting injury.