On March 28, 2023, Pennsylvania Attorney General Michelle Henry announced charges against two nurses who neglected their duty to care for a resident who died after sustaining injuries at a nursing home in Dauphin County. Nurse 1 was charged with felony neglect of a care-dependent person and misdemeanor tampering with or fabricating evidence. Nurse 2 was charged with a misdemeanor count of neglect of a care-dependent person.
Both women were nurses at the facility in December 2019 when a male resident fell and was seriously injured. He was later hospitalized and died on Jan. 1, 2020. A Grand Jury investigation revealed that neither nurse followed protocol in how they responded to the man’s condition. Nurse 1 was also charged with covering up the conduct by omitting and misstating information on the man’s medical chart.
The investigation revealed that on December 25, 2019, Nurse 2, a Licensed Practical Nurse (LPN) who was responsible for overseeing the nursing care for all residents on her assigned floor, was called to the man’s room after staff found him on the floor. According to the facility’s policy, an incident of this nature was considered an unwitnessed fall and required Nurse 2 to document the incident and call a Registered Nurse (RN) to assess the resident for injuries and put in place specific monitoring protocols to check for latent injuries. However, Nurse 2 disregarded facility policy and directed staff to pick the man up off of the floor without assessing him for injury herself, documenting the incident, or calling an RN.
Days later, on December 29, 2019, Nurse 1, a Registered Nurse, was working as an RN Supervisor at the facility. She was responsible for the nursing care for all of the residents in her assigned building during her shift. She was called to the man’s room after staff once again found him on the floor. Although several witnesses reported concerns with the man’s condition, which included a visible injury to his head, Nurse 1 failed to follow established protocol to ensure the man was properly assessed and monitored for latent injuries. He was diagnosed with a subdural hematoma before he passed away on January 1, 2020.
Both defendants were charged on March 24; Nurse 2 was arraigned that same day; Nurse 1 was arraigned on March 27. Bail was set at $10,000 unsecured for both defendants.
“The defendants were responsible for the safety and wellbeing of the residents under their supervision. They had multiple opportunities to provide this resident with the care he urgently needed, but failed to fulfill their duties as nurses and caregivers,” said AG Henry. “Our office is committed to protecting the safety of seniors and care-dependent Pennsylvanians, and will work tirelessly to hold accountable those who knowingly neglect vulnerable individuals.”
Compliance Perspective
Issue
F689 states that the resident environment must remain as free of accident hazards as possible, and each resident should receive adequate supervision and assistance devices to prevent accidents. The requirement includes identifying and evaluating hazards and risks, implementing interventions to reduce hazards and risks, monitoring for effectiveness, and modifying interventions when necessary. If a fall occurs, the resident must be assessed thoroughly, and the plan of care updated to reduce the likelihood of future falls. The physician should be notified promptly of all falls, and if a change in condition occurs, the physician must be notified immediately. Failure to prevent falls can be considered provision of substandard quality care, and may result in an immediate jeopardy citation, fines, and lawsuits.
Discussion Points
- Review policies and procedures for resident safety, including fall prevention protocols, to ensure that they provide evidence-based interventions to reduce injuries and falls. Also review your policies and procedures for reporting and documenting incidents/accidents to ensure they meet current requirements.
- Train all appropriate staff on resident safety policies and procedures, documentation, and reporting requirements. Document that the trainings occurred, and file the signed documents in each employee’s education file.
- Periodically audit care plans to ensure that they are appropriate, person-centered, and contain evidence-based interventions to keep residents free from injury, that interventions are revised as needed, and that staff are informed of changes. Audit your incident/accident reports to ensure that all issues where reporting is required were managed timely with appropriate follow-up, and that documentation is complete.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
