Failure to Timely Report and Investigate Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to ensure timely reporting and investigation of an allegation of neglect involving a male resident with intact cognition, multiple diagnoses including unsteadiness on feet, and a high risk for falls. The resident, who required maximum assistance for transfers, fell in the bathroom after attempting to transfer independently when staff did not respond to his call light. He subsequently called 911 for assistance, and emergency medical services helped him back into his wheelchair. Documentation indicated that the resident's call light was within reach, but he did not use it to call for help before transferring; however, during interview, the resident stated he had pressed the call light and waited as long as he could before attempting to transfer on his own due to lack of staff response. Interviews and record reviews revealed that both the CNA and RN assigned to the resident were on break at the same time, leaving the resident without assigned staff assistance. Other staff members were present in the building, but not assigned to the resident's hall. The Director of Nursing (DON) investigated the fall by speaking to staff but did not interview the resident initially, nor did she contact EMS for additional information. The DON was unaware that both assigned staff were on break simultaneously and did not self-report the incident as neglect because she did not realize the full circumstances at the time. The facility's policy requires immediate reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, to the administrator and appropriate authorities. In this case, the incident was not self-reported as neglect, and the required investigation steps, including interviewing the resident and contacting EMS, were not completed in a timely manner. The administrator later acknowledged that if she had known both assigned staff were on break, she would have self-reported the incident as neglect.