Failure to Timely Report Serious Fall Injury to State Agency
Penalty
Summary
The facility failed to timely report a fall with serious injury to the State Agency (SA) for a resident with a history of multiple falls and significant neurological impairment, including hemiplegia and hemiparesis following a stroke. The resident experienced several falls over a short period, with no comprehensive analysis or implementation of appropriate interventions to prevent further incidents. On one occasion, the resident was found on the floor with a head injury and was subsequently sent to the emergency department, where a brain bleed was identified. Despite this serious injury, there was no evidence that a comprehensive fall investigation or analysis was completed by the facility. Interviews revealed that staff were unclear about reporting requirements, with an LPN assuming that the assistant director of nursing (ADON) would notify the administrator and being unaware of the obligation to report to the SA. The administrator and director of nursing (DON) both acknowledged that the incident should have been reported to the SA within two hours of learning about the brain bleed, but this did not occur. The facility's own policy required prompt reporting of serious injuries, but this was not followed in this case.