Failure to Protect Resident from Neglect and Delay in Reporting Fall
Penalty
Summary
A deficiency occurred when a resident with advanced dementia, severe cognitive impairment, and a history of falls was not protected from neglect. The resident required assistance from two staff members for all transfers, as documented in her care plan and physical therapy evaluations. Despite these directives, a nurse aide (NA) transferred the resident alone using an EZ stand, left her unattended on the edge of the bed, and the resident subsequently fell, sustaining a laceration to her forehead, bruising, a concussion, and a fracture of the sternum. Following the fall, the NA did not immediately report the incident or seek medical attention for the resident. Instead, the NA cleaned the resident, changed her clothing, attempted to stop the bleeding, and placed her back in bed without notifying a nurse or following facility policy, which required immediate reporting and assessment by a licensed nurse before moving a resident after a fall. The incident was not reported until approximately two hours later, resulting in a delay in necessary medical care. The NA also attempted to conceal the incident by disposing of bloody clothing and providing false information to staff and investigators. Interviews and documentation revealed that staff were aware of the resident's need for two-person assistance and her inability to safely sit on the edge of the bed unattended. The NA's actions were contrary to the care plan and facility policies, and the delay in reporting and seeking care contributed to the severity of the resident's injuries. The incident was later investigated by facility leadership and law enforcement, confirming that the NA acted alone, failed to follow the care plan, and intentionally delayed reporting the fall.
Removal Plan
- Implemented immediate resident protection.
- Revised R1's Care Plan to include stand pivot transfer with assist of two if alert.
- Implemented Hoyer lift, assist of two with medium sling.
- Re-educated staff on Abuse/Neglect/Accident Reporting, providing safe and appropriate care, and resident protection.
- Verified education through interview and training records.