Failure to Timely Report Serious Injury and Alleged Improper Transfer
Penalty
Summary
The deficiency involves the facility’s failure to timely report a serious injury and alleged improper transfer of a cognitively intact resident to the appropriate state agencies within the required timeframe. The resident had right-sided hemiplegia/hemiparesis due to cerebrovascular disease, contracture of the right wrist, muscle weakness, and required assistance with personal care. The care plan documented behaviors including false accusations and indicated the resident required two-person care and Hoyer lift transfers. A quarterly MDS showed a BIMS score of 15, indicating the resident was cognitively intact and had no documented mood or behavioral indicators. On one morning, the resident reported right shoulder pain to nursing staff, leading to physician notification and a STAT x-ray order. The x-ray later revealed a moderately displaced comminuted fracture of the surgical neck of the right humerus, and an orthopedic report documented swelling, bruising, and tenderness over the proximal humerus. The facility’s internal investigation, initiated the same day, included an interview with a CNA who stated that he and another CNA had transferred the resident from wheelchair to bed using a Hoyer lift per protocol and without incident. Other staff interviews indicated the resident reported arm soreness and pain, requested to see the doctor, and was known to be a two-person Hoyer lift transfer. The resident later reported that on the prior day a CNA had transferred her by wrapping his arms around her shoulders and lifting her from wheelchair to bed instead of using the Hoyer lift, that she heard a crack and felt pain, and that she informed the CNA and then an LPN and the DON about the pain and bruising. The DON acknowledged that the resident approached her and reported shoulder pain and an incorrect transfer, and that an investigation was started that same day. Despite the facility’s policy requiring that all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source, be reported immediately but not later than two hours if the events involve abuse or result in serious bodily injury, the DON did not make required notifications to the state agency, APS, Ombudsman, or police. The DON stated she believed reporting was not required because the complainant was known to make false accusations, even though a major injury had occurred and an investigation into the cause of the injury was underway. The incident was not reported to the state agency until 26 days after the facility became aware of the fracture, and only after APS reported the incident to the facility.
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