Failure to Timely Report Resident Fall with Major Injury
Penalty
Summary
The facility failed to report a serious incident involving a resident who sustained major injuries from a fall within the required two-hour timeframe to the South Dakota Department of Health (SD DOH). The resident, who was moderately cognitively impaired with a BIMS score of 10, fell from a whirlpool tub chairlift while being transferred by a CNA. The safety belt had been loosened at the resident's request but not removed. Following the fall, the resident was found unconscious and bleeding from the forehead, and was subsequently sent to the emergency room where he was diagnosed with two subarachnoid hemorrhages, a closed nasal bone fracture, and lacerations to the forehead and right lower extremity. Despite the facility's policy requiring immediate reporting of incidents involving serious bodily injury within two hours, the initial Facility Reported Incident (FRI) was not submitted to the SD DOH until nearly 22 hours after the event. Interviews with staff, including the social worker, administrator, and DON, confirmed the delay in reporting and acknowledged that the facility was not consistent in meeting the required reporting timeframe for major injuries. The facility's policy and staff expectations were reviewed, highlighting the lapse in timely notification to the appropriate authorities.