Failure to Report and Assess Resident Fall Resulting in Neglect
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not report a fall incident and did not assess the resident for injuries as required by facility policy. The resident, who had diagnoses including Alzheimer's disease, depression, and difficulty swallowing, had a physician order to ambulate with supervision. On the evening in question, two nurse aides were transferring the resident from a wheelchair to bed when they were unable to support his weight and lowered him to the floor. The aides did not notify a nurse of the incident, deciding among themselves not to report it because they did not consider it a fall. The following day, another staff member noticed significant swelling, bruising, and abnormal positioning of the resident's leg during morning care. The nurse was immediately alerted, and subsequent evaluation revealed a left hip fracture, leading to the resident's hospital admission. Documentation and staff interviews confirmed that the nurse aides involved in the transfer did not inform nursing staff of the incident, and the resident was not assessed for injury until the next shift discovered physical signs of trauma. Interviews with facility staff, including the DON and other nurse aides, confirmed that the event was not reported as required and that staff were aware of the policy to report any change of plane or fall. The failure to report and assess the resident after the incident resulted in a delay in identifying and treating a serious injury, constituting neglect under facility policy and regulatory requirements.