Failure to Timely Report Allegations of Neglect Resulting in Resident Injuries
Penalty
Summary
The facility failed to ensure timely reporting of allegations of neglect for two residents. In one case, a resident who required a mechanical lift for all transfers sustained a right knee fracture during a transfer performed by an LPN using a pivot turn, as the lift could not be located. The LPN did not report the incident immediately because there were no apparent issues after the transfer, and the resident only complained of knee pain later. The Administrator filed a state Adverse report for the fracture due to failure to follow the plan of care but did not initiate a neglect investigation, believing the issue was limited to not following the care plan. In another case, a resident was hospitalized with a fractured hip after an incident involving another resident's wheelchair coming into contact with her leg, causing her to yell out. A bruise was found the next day in the same area, but staff did not believe the incident was severe enough to cause injury and did not report it as neglect. The Administrator stated that a federal report was not filed because they did not feel the incident rose to the level of neglect. The facility's policy defines neglect as the failure to provide necessary goods or services to avoid harm, and federal requirements mandate timely reporting of such allegations.