Failure to Immediately Report and Investigate Alleged Neglect Following Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that all allegations of neglect were reported immediately to the Pennsylvania Department of Health for one resident. The facility's policy requires that all incidents involving mistreatment, neglect, abuse, or injuries of unknown origin be reported immediately to the Director of Nursing (DON) and Administrator for further review and reporting as per state and federal regulations. However, in this case, a resident who was dependent on staff for bed mobility and transfers, and required the assistance of two staff members, experienced a fall from bed while being cared for by a single certified nurse aide who was also using a personal cellphone and wearing earbuds during the incident. The resident, who was cognitively intact and bedbound due to multiple medical conditions including muscle weakness and multiple sclerosis, reported that the aide was alone and distracted at the time of the fall. The aide did not report the incident to nursing staff during the shift, and the resident was not assessed by nursing staff until the following day, after she reported knee pain. Documentation shows that the facility only became aware of the fall when the resident informed a licensed nurse the next day, at which point an assessment and investigation were initiated. Interviews and internal investigation confirmed that the certified nurse aide failed to follow the resident's care plan, which required two-person assistance for bed mobility, and did not report the fall to nursing staff as required. The Director of Nursing confirmed that staff failed to notify nursing staff on both the evening and overnight shifts, resulting in a delay in reporting the incident and initiating appropriate follow-up.