Failure to Timely Report Significant Injury to State Agency
Penalty
Summary
The facility failed to notify the required State Agency of a significant injury within the required time frame for one resident. The resident, who had a history of falling, schizoaffective disorder, bipolar type, violent behavior, traumatic subdural hemorrhage, and chronic pain, experienced a fall that resulted in surgery and a subsequent hospital stay. The resident was assessed by an LPN, who determined that an emergency room visit was necessary and called 911. The DON and Administrator were made aware of the situation at the time of the incident. Despite being aware of the resident's transfer to the emergency room, the DON did not become aware of the need for surgery and hospital admission until the following day. The facility's policy requires immediate reporting, but Adult Protective Services was not notified until the morning after the surgery and hospitalization. This delay in reporting did not meet the facility's policy or regulatory requirements for timely notification of significant injuries.