Failure to Investigate Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a male resident with intact cognitive ability, who was at risk for falls due to immobility, muscle weakness, diabetes, and chronic pain. The resident required maximum assistance for transfers and had a care plan intervention to keep the call light within reach at all times. On the night of the incident, the resident attempted to transfer from his wheelchair to the toilet independently after waiting for staff assistance that did not arrive, resulting in a fall. He called 911 for help, and emergency personnel assisted him back into his wheelchair. Documentation indicated that the resident was alert, oriented, and had no injuries, but staff education was provided regarding the use of the call light system. Interviews and record reviews revealed that both the CNA and RN assigned to the resident were on break at the same time when the fall occurred, leaving the resident without immediate assistance. The resident reported pressing his call light and waiting as long as he could before attempting the transfer himself. He also stated that he yelled for help after falling, but no staff responded, prompting him to call 911. Other staff confirmed that the assigned CNA and RN were outside on break, and the DON was unaware that both were absent from the unit simultaneously. The facility's investigation into the incident was incomplete, as the DON did not initially interview the resident or contact EMS for additional information. The DON relied on staff accounts and did not recognize the need to self-report the incident as neglect, as she was unaware that both assigned staff were on break at the same time. The facility policy required prompt investigation of any allegations of abuse, neglect, or mistreatment, but this was not fully carried out in this case.