Failure to Timely Report Neglect After Resident Falls From Transport Van
Penalty
Summary
The facility failed to timely report an allegation of neglect to the administrator and to the State Survey Agency within 24 hours as required by its abuse reporting and transportation policies. The facility’s Abuse Reporting and Investigation Policy required all alleged violations involving neglect to be reported immediately, but not later than 24 hours, to the state licensing/certification agency, and defined neglect to include failure to provide timely, consistent, safe, adequate, and appropriate care and services. The Transportation Policy required all incidents and accidents, no matter how minor or major, to be reported immediately to the administrator. Resident #1, admitted with diagnoses including ataxia, was being transported in the facility van when the rear door opened and the resident rolled or fell out into the parking lot. An incident report documented that this occurred outside at 12:30 p.m., with no injuries noted. The transport driver (S3TD) acknowledged that he was responsible for transporting residents and that Resident #1 fell out of the van while he was driving. He admitted he did not notify administration at the time because the resident did not complain of pain or injuries, despite knowing he should have reported the incident. The DON (S2DON) stated he became aware of the fall at 12:45 p.m. the same day, and that the driver had not notified him when it occurred; he later informed the administrator (S1ADM) after a passerby notified the facility that the resident had fallen from the van. The administrator stated she was responsible for reporting neglect to the state agency and that she was informed of the incident by the DON, but she did not consider it neglect at the time and did not report it to the state agency. She later confirmed that the driver’s failure to secure the resident in the van, resulting in the resident falling out, was neglect and should have been reported within the 24-hour timeframe.
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