Failure to Timely Report Resident Injury and Death
Penalty
Summary
A deficiency occurred when the facility failed to immediately report an alleged violation involving a resident found unresponsive on the floor with a hematoma on the forehead. The resident, who had a medical history including neoplasm of the lung and prostate, atrial fibrillation, and chronic obstructive pulmonary disease, was discovered by staff without vital signs and was later pronounced deceased by emergency services. Despite the presence of visible injuries, the incident was not reported to the Director of Nursing, the Administrator, or the New York State Department of Health as required by facility policy and state regulations. Interviews and record reviews revealed that the Registered Nurse Supervisor did not initiate an investigation or complete an incident report regarding the unwitnessed fall and injury. The Director of Nursing and Administrator both confirmed they were not informed of the fall or injury, and thus no report was made to the appropriate authorities. The facility's own policy required such incidents, especially those involving injury of unknown origin, to be assessed, documented, and reported promptly to both internal leadership and external agencies. The incident only came to the attention of the Department of Health after the resident's next of kin reported it, having observed bruising and blood on the resident's face upon viewing the body. The facility was unable to explain the injuries to the family, and an autopsy was subsequently requested. Review of facility records confirmed there was no documentation or reporting of the incident as required.