Failure to Timely Report Unwitnessed Fall with Injury
Penalty
Summary
The facility failed to report an unwitnessed fall with injury involving one resident to the California Department of Public Health (CDPH) as required. The resident, who had a history of polyarthritis, muscle weakness, difficulty walking, and moderate cognitive impairment, experienced an unwitnessed fall in their room and was found by a CNA with a significant bump on the forehead. The incident was documented in the resident's records, and the resident was transferred to the hospital for further evaluation. Despite the facility's policy requiring reporting of unusual occurrences and injuries of unknown source within 24 hours, the incident was not reported to CDPH in a timely manner. Interviews with facility leadership confirmed that the administrator was unaware of the fall and injury, and the assistant director of nursing acknowledged that the event met the criteria for mandatory reporting. The facility's policies on unusual occurrence reporting and abuse prevention both specified that such incidents affecting resident welfare, health, or safety must be reported promptly to state authorities. The failure to report the unwitnessed fall with injury resulted in a delay in investigation by CDPH.