Failure to Report Resident Fall to State Authorities
Penalty
Summary
The facility failed to report a fall incident involving a resident in accordance with its own policy and regulatory requirements. The resident, who had a history of falls, chronic obstructive pulmonary disease (COPD), and type II diabetes, experienced an unwitnessed fall resulting in a nasal fracture. The resident required moderate assistance with daily activities and had moderate cognitive impairment. After the fall, the nurse on duty notified the physician, obtained an x-ray order, informed the conservator, and followed the internal chain of command by notifying the Director of Nursing (DON) and the administrator. The resident was subsequently transferred to the hospital for further care. Despite these internal notifications, the facility did not report the fall to the California Department of Public Health (CDPH) or other appropriate agencies as required by both facility policy and state regulations. Interviews with staff, including the Registered Nurse Supervisor, Director of Staff Development, and the administrator, revealed a lack of understanding or misinterpretation of the reporting requirements. The facility's policy clearly states that unusual occurrences affecting resident welfare must be reported to appropriate agencies within specified timeframes, but this protocol was not followed, resulting in a delay in external investigation and potential interventions.