Failure to Report Major Accidental Fall with Injury
Penalty
Summary
The facility failed to ensure its policy for Unusual Occurrence Reporting included major accidents and did not follow state and federal regulations to report a major accidental fall with injury. A resident with a history of unsteadiness, repeated falls, Parkinson's disease, osteoarthritis, and cognitive impairment experienced a witnessed fall while attempting to use a walker, resulting in a right femur fracture. The resident was transferred to the hospital for treatment and later readmitted to the facility. Despite the severity of the injury, the incident was not reported to the State Agency as required. Review of the facility's policy revealed it did not specify major accidents as reportable events, and both the DON and Administrator stated they did not consider the incident reportable because the fall was witnessed and the cause was known. However, state regulations require reporting of major accidents, regardless of whether the cause is known. The facility's outdated policy and misunderstanding of reporting requirements led to the failure to report the incident in accordance with applicable laws.