Failure to Report Serious Injury of Unknown Source and Neglect
Penalty
Summary
The facility failed to report an allegation of serious injury of unknown source and neglect for a resident who experienced an unwitnessed fall resulting in a skull fracture. The resident, who had a history of cognitive impairment, dementia, and confusion, was found on the floor with facial injuries and was subsequently diagnosed with a skull fracture and scalp contusion at the hospital. Her care plan included interventions such as the use of a mechanical lift with two staff for transfers and keeping the call light within reach, but she attempted to get out of bed without assistance. Interviews revealed that the DON did not consider the incident an adverse event or injury of unknown source, stating there was no violation of the care plan since the resident did not call for help. The DON also indicated that the event did not need to be reported to the State Agency. However, the resident's PMHNP and an LPN both described the resident as very confused and unable to use the call light or request assistance, contradicting the DON's assessment of the resident's capabilities. The PMHNP was not informed of the fall, and the LPN stated the resident would not have known how to use the call light. A review of facility policy showed that all reports of abuse, neglect, or injuries of unknown origin are to be reported to local, state, and federal agencies as required by regulations. The policy also requires immediate reporting of suspected abuse, neglect, or injury of unknown source to the administrator and other officials according to state law. Despite these requirements, the facility did not report the incident as required.