Failure to Report Resident Falls Within Required Timeframe
Penalty
Summary
The facility failed to report serious incidents involving a resident to the Department of Health within the required 24-hour timeframe. Resident 48, who had diagnoses including dementia, anxiety disorder, and frequent falls, experienced two significant falls that required hospital transfers. The first incident occurred on February 16, 2025, when the resident fell, resulting in a hematoma on the forehead and abrasions on the arm and finger, leading to a hospital transfer for further evaluation and treatment. The second incident took place on February 23, 2025, when the resident fell again, sustaining a bump on the forehead and a scratch on the arm, and was transferred to the hospital due to a closed head injury and ambulatory dysfunction. The facility did not report either of these incidents to the Pennsylvania Department of Health's event reporting system. During an interview, the Director of Nursing confirmed that the first fall should have been reported but was not. The second fall was not reported because the transfer was attributed to the resident's ambulatory dysfunction rather than the fall itself. The DON was not informed about the hematoma at the time of the incident, which contributed to the failure to report the incident as required.
Plan Of Correction
1. R48 was reported as required on 4/8/25. 2. No other ERS reporting was identified as not submitted. Education was provided by the Regional Clinical nurse or designee to the new DON on ERS reporting requirements. 3. Incident reports will be audited by the DON or designees to ensure that any incidents requiring reporting is completed timely weekly x 4. 4. Audits will be taken to QAPI for review and further interventions if warranted.