Failure to Timely Report Unwitnessed Fall with Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately as required. Specifically, an unwitnessed fall involving a resident with significant cognitive and physical impairments was not reported to the State Survey Agency or adult protective services. The resident, who had a history of falls, cognitive communication deficits, and was totally dependent on staff for mobility and activities of daily living, sustained a head injury resulting in significant bleeding and required transfer to a hospital, where she received four stitches. Despite the resident's inability to communicate the circumstances of the fall and the presence of a serious injury, the Director of Nursing (DON) did not report the incident to the state, stating that she did not suspect abuse. The administrator indicated that unwitnessed falls with head injuries should be reported, but in this case, the required reporting did not occur. Staff interviews and record reviews confirmed that the incident was not reported as mandated, and the facility's in-service records showed that staff had received training on abuse and neglect prior to the event.