Failure to Report Resident Injury to State Authorities
Penalty
Summary
A facility failed to report an injury involving a severely cognitively impaired resident to the New Jersey Department of Health (NJDOH). The resident, who had diagnoses including Alzheimer's Disease, dementia, and hypertension, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. According to the medical record and incident report, the resident was found face down on the floor after falling from a wheelchair while reaching for candy, resulting in a head laceration. The resident was transferred to the hospital, where they received seven staples to the forehead for the injury. Review of the incident report and facility documentation did not show evidence that the NJDOH had been notified of the incident, as required. During interviews, facility staff stated that the incident had been investigated and reported to the NJDOH by a previous administrator, but no documentation was provided to confirm this. The surveyor did not receive any additional documentation indicating that the NJDOH had been contacted regarding the incident.