Failure to Timely Report Significant Injuries from Unwitnessed Falls
Penalty
Summary
The facility failed to report allegations of potential abuse and/or neglect in a timely manner for three out of five residents reviewed for significant falls with injury. According to the Washington State Department of Social and Health Services (DSHS) Nursing Home Guidelines, substantial injuries of unknown sources and resident-to-resident altercations with physical abuse are incidents that require reporting to the DSHS Hotline. The facility's own policy also mandates prompt reporting of injuries of unknown source to local, state, and federal agencies, followed by thorough investigation by management. For one resident with dementia and a history of repeated falls, an unwitnessed fall resulted in a swollen eye, bleeding from the back of the head, and a laceration requiring sutures. This incident, which involved substantial injuries to areas not generally vulnerable to trauma, was not reported to the state agency. Another resident with end stage renal disease and repeated falls experienced an unwitnessed fall resulting in a vertebral fracture and hospitalization, but this incident was also not reported. The Director of Nursing Services acknowledged that the process for reporting unwitnessed falls with injuries was not followed in this case. A third resident, with polyneuropathy and repeated falls, was found on the floor of their restroom after an unwitnessed fall, resulting in bruising and a broken toe confirmed by x-ray five days later. This incident was similarly not reported to the state agency, as staff did not consider it reportable. These failures to report significant injuries from unwitnessed falls represent a lack of adherence to both state guidelines and facility policy.