Failure to Report Major Injury Fall to State Agency
Penalty
Summary
The facility failed to report a resident's fall that resulted in a major injury to the State Agency as required. The resident involved had a history of hemiplegia and hemiparesis following a stroke, insomnia, delusions, major depressive disorder, a displaced closed fracture, and a history of falls. The resident required substantial assistance for activities of daily living and had a care plan directing staff to use a gait belt and provide two-person assistance for transfers. Despite these directives, the resident experienced a fall during a transfer when only one CNA assisted, and a gait belt was not used. Following the fall, the resident complained of pain and was later transported to the hospital, where a hip fracture was diagnosed and surgical intervention was performed. Documentation in the electronic medical record indicated that the resident had expressed pain and discomfort after the fall, and the incident was discussed by the interdisciplinary team. The CNA involved reported feeling pressured by the resident to proceed with the transfer alone and acknowledged not following the required protocol for assistance. Despite the severity of the injury and the circumstances of the fall, administrative staff did not report the incident to the State Agency. The rationale provided was that the resident was able to communicate what had happened and initially reported only mild pain, with the extent of the injury not becoming apparent until the following day. The facility's policy required prompt investigation and reporting of accidents and incidents, but this protocol was not followed in this case.