Failure to Report Injury of Unknown Origin Following Unwitnessed Fall
Penalty
Summary
A deficiency occurred when the facility failed to report an injury of unknown origin for a resident with severe cognitive impairment and multiple comorbidities, including dementia, coronary artery disease, and a history of falls. The resident was found on the floor by a CNA, who notified a nurse. The nurse assessed the resident, noted a scratch on the arm, and, with assistance, transferred the resident to a wheelchair. The resident was combative during the transfer and did not verbalize pain, but no further assessment or documentation of the incident as a fall was completed at that time. The nurse did not notify the physician, DON, or complete an incident report as required by facility policy. The resident continued with daily activities, and later that day, a family member transferred the resident to bed and noted the resident was in pain. The family member informed staff, but the incident was still not reported as a fall or injury of unknown origin. Two days later, the family member reported the resident's pain to the hospice nurse, who then ordered a STAT X-ray, revealing an acute right hip fracture. The DON was only made aware of the incident at this point and initiated an investigation, confirming that the nurse had not followed policy for reporting unwitnessed falls or changes in condition. Interviews with staff revealed a lack of understanding and adherence to facility policy regarding the reporting of accidents and changes in condition. The nurse involved assumed the resident's behavior was typical and did not consider the possibility of injury, while the CNA followed protocol by notifying the nurse but did not escalate the incident further. The facility's policies required immediate reporting and documentation of unusual occurrences, as well as physician and family notification for significant changes in condition, which were not followed in this case.