Failure to Report Resident Fall Resulting in Fracture
Penalty
Summary
The facility failed to notify the Department of Health of a reportable event involving a resident who experienced an unwitnessed fall. This incident occurred on April 19, 2025, and resulted in the resident sustaining a lumbar compression fracture, a type of spinal fracture where the vertebrae collapses. The clinical record review confirmed that the resident did not have a prior diagnosis of a lumbar compression fracture before the fall. During interviews, the Director of Nursing stated that the incident was not reported because the resident did not require hospitalization. Both the Nursing Home Administrator and the Director of Nursing acknowledged that the facility did not notify the Department of Health about this reportable event, which is a requirement under the regulations for events that seriously compromise quality assurance and patient safety.
Plan Of Correction
1. Reportable submitted and accepted for identified fall during complaint survey on 5/1/2025. 2. A 30 day look back audit was completed to ensure that no other falls experienced an injury of similar nature and went unreported. 3. NHA to educate DON/designee on events that require a report to be submitted. 4. DON/designee to audit falls and ensure reports are made for any falls with transfer and/or injury daily x 2 weeks, then 2x/week for 2 weeks, and 1x/week for 2 weeks. 5. Results to be submitted to QAPI for review and approval.