Failure to Timely Report Serious Resident Injuries to State Agency
Penalty
Summary
The facility failed to report two significant incidents involving a resident to the state agency as required by their own policy and regulatory guidelines. The first incident involved a resident with severe cognitive impairment and dependency on staff for activities of daily living, who experienced a fall resulting in a head laceration that required a staple. The fall was unwitnessed, and the resident was found on the floor by staff. After being transferred to the hospital for evaluation and treatment, the resident returned with a staple in the forehead. Despite the seriousness of the injury, there was no evidence that the incident was reported to the state agency. The second incident involved the same resident, who suffered another unwitnessed fall while in a common area, resulting in a displaced fracture of the right femoral neck that required surgical repair. The resident, who does not ambulate independently and uses a wheelchair, was found on the floor and complained of severe pain in the right knee and lower leg, with visible swelling and deformity. Hospital records confirmed the fracture and subsequent surgery. The facility did not report this incident to the state agency until ten days after the fall, which was not in accordance with the required reporting timelines. Interviews with the Director of Nursing and the Administrator confirmed that both were aware of the incidents and acknowledged that the events should have been reported to the state agency as required. The facility's policy mandates immediate reporting of such incidents, especially those resulting in serious bodily injury, but this protocol was not followed in either case.