Failure to Timely Report Serious Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident of an unwitnessed fall resulting in serious injury for one resident within the required two-hour timeframe to the State Survey Agency, as mandated by regulation and facility policy. The resident, an elderly female with Alzheimer's disease, anxiety disorder, and Parkinson's disease, was identified as being at risk for falls and was ambulatory with a walker. On the date of the incident, she was found on her bedroom floor with blood on the back of her head and complaints of neck and back pain, less than 30 minutes after last being seen in bed by staff. She was subsequently transported to the hospital, where she was diagnosed with a subdural hematoma and subarachnoid hemorrhage related to the unwitnessed fall. Despite the serious nature of the injury and the requirement to report such incidents of unknown origin within two hours, the facility did not notify the State Survey Agency. Interviews with the DON, Administrator, LVN, and CNA confirmed that the event was not reported because staff believed the circumstances of the fall were known, as it occurred in the resident's room. The facility also did not provide in-service training to nursing staff related to this incident, as it was not self-reported to the authorities. The facility's own policy required reporting injuries of unknown origin with serious bodily injury, but this was not followed in this case.