Failure to Accurately Report Resident Impalement and Associated Injuries
Penalty
Summary
The facility failed to accurately report an incident of neglect involving an unsafe environment to the State Agency. A resident with moderate cognitive impairment, a history of falls, and limited mobility due to being wheelchair-bound, attempted to get out of bed and fell onto a metal bed frame. This resulted in a penetrating trauma, with the metal frame impaling the resident's left buttock by approximately 3-4 inches, causing significant blood loss, a comminuted fracture of the left inferior pubic ramus and ischial tuberosity, and a 4 cm laceration near the anal region. Emergency services documented the severity of the injuries, including the impalement and associated trauma. However, the facility's investigation report, authored by the Nursing Home Administrator, did not include critical details about the impalement, blood loss, or the extent of the injuries, instead only noting a fall and subsequent fracture discovered after hospital evaluation. During interviews, the administrator acknowledged that the information provided to the State Agency should have included all apparent injuries linked to the incident but was unable to explain the omission of the impalement and blood loss from the report. This resulted in inaccurate information being reported to the State Agency regarding the incident.