Failure to Report Injury of Unknown Origin and Major Accident to State Authorities
Penalty
Summary
The facility failed to report an injury of unknown origin and a major accident involving a resident to the California Department of Health (CDPH) as required by their own policy and state regulations. The resident, who had multiple diagnoses including cognitive impairment, muscle weakness, and difficulty walking, experienced several unwitnessed falls over a period of days. Documentation shows that the resident suffered a head injury resulting in a bruise and bump on the forehead, and subsequently exhibited a change in condition, including altered mental status and abnormal vital signs. Despite these events, which included a significant change in the resident's condition and eventual transfer to the hospital, the facility did not notify CDPH within the required timeframe. The resident was found to have extensive intracranial bleeding on hospital evaluation and later died as a result of a subdural hematoma caused by the unwitnessed fall. The facility's policy required reporting of major accidents and other occurrences affecting resident welfare to the appropriate authorities within 24 hours, but this was not followed in this case. Interviews with facility staff, including the DON, confirmed that the incident was not reported to CDPH because the resident was sent to the hospital and did not return to the facility. The lack of timely reporting delayed the involvement of required agencies in investigating the injury of unknown origin and determining whether abuse or neglect may have been a factor.