Failure to Investigate and Report Resident Fall Resulting in Injury and Death
Penalty
Summary
The facility failed to investigate a fall accident that resulted in injuries and subsequent death for one resident. On the specified date, a Licensed Practical Nurse found the resident lying face down on the floor next to their bed, unresponsive and without vital signs, with a hematoma on the forehead. Cardiopulmonary resuscitation was initiated and emergency services were called, but the resident was pronounced dead by the emergency medical team. The incident was not reported to the Director of Nursing or the Administrator, and no investigation into the unwitnessed fall and injury was initiated by the Registered Nurse Supervisor. There was no incident report related to the event, and the facility was unable to explain the blood and bruising observed by the resident's next of kin. The resident had a medical history including neoplasm of the lung and prostate, atrial fibrillation, and chronic obstructive pulmonary disease, and was assessed as having intact cognition. The facility's policy required assessment, documentation, and reporting of incidents such as falls, but these procedures were not followed. The Director of Nursing and Administrator were not notified of the incident, and the required investigation and documentation were not completed. The deficiency was identified through interviews, record review, and the absence of an incident report for the event.