Failure to Investigate and Report Injury of Unknown Origin with Serious Bodily Injury
Penalty
Summary
The facility failed to provide evidence that all allegations of injuries of unknown origin involving serious bodily injury were thoroughly investigated and documented for one resident. Specifically, a female resident with Alzheimer's disease, anxiety disorder, and Parkinson's disease experienced an unwitnessed fall in her room, resulting in blood on the back of her head, complaints of neck and back pain, and subsequent hospital admission where she was diagnosed with a subdural hematoma and subarachnoid hemorrhage. Despite the serious nature of the injury, there was no facility self-report investigation or documentation of a thorough investigation related to the incident. Interviews with the DON and Administrator confirmed that the event was not reported to the state health authority, and no in-service training or internal investigation was completed, as the facility believed the circumstances of the fall did not require reporting. Review of facility policy indicated that such incidents should be reported and investigated, but this was not followed in this case.