Failure to Accurately Report Incident and Care Plan Deviation to State Agency
Penalty
Summary
The facility failed to submit a report to the State Agency (SA) with sufficient and accurate information regarding an incident involving a resident with Alzheimer's disease, vascular dementia, and impaired mobility. The resident, who was non-ambulatory and required transfer assistance using an EZ mechanical stand with one staff member, experienced a staff-assisted fall when a nursing assistant attempted a pivot transfer instead of using the required mechanical lift. This deviation from the care plan resulted in the resident being lowered to the floor, and subsequent imaging revealed a slightly displaced fracture of the distal fibula. The incident report submitted to the SA did not include the critical detail that the resident was transferred by pivot with one staff member rather than with the mechanical lift as required by the care plan. Further review of communications and interviews revealed that the Director of Nursing (DON) did not provide complete information to the SA regarding the root cause of the fall or the failure to follow the resident's care plan, despite being aware of these facts from internal reports and staff communications. The DON confirmed that the report was submitted after the fracture was identified but was unsure why the report omitted the details about the improper transfer method. Additionally, the facility had not conducted a full investigation or interviewed the involved staff or resident before submitting the report, even though the incident report and verbal communications indicated the care plan was not followed.