Failure to Report Major Injury After Resident Fall
Penalty
Summary
The facility failed to report a major injury involving a resident who was left unattended on a patio by a Restorative Nursing Assistant for 30 minutes. During this time, the resident, who had vascular dementia, hemiplegia, hemiparesis, and muscle weakness, fell and was found unresponsive with shallow breathing and unstable vital signs. The resident was transported to a hospital, where a CT scan revealed a small acute subdural hematoma with a midline shift. The resident was later returned to the facility on hospice care and subsequently died that evening. Despite the severity of the injury, which met the CMS definition of a major injury, the facility did not report the incident to the appropriate authorities. Both the Administrator and the Director of Nursing stated in interviews that they did not consider the injury significant or an unusual occurrence, and therefore did not report it. This failure delayed the investigation into the major injury and was not in accordance with facility policy or professional standards of practice.