Failure to Report and Investigate Serious Fall Resulting in Hip Fracture
Penalty
Summary
The facility failed to implement and uphold its policies and procedures for reporting an unwitnessed fall involving a resident who was not a reliable reporter. The resident sustained a hip fracture, required surgery, and was hospitalized as a result of the fall. Despite the severity of the injury and the resident's unreliable reporting, the incident was not reported to the State Survey Agency as required. Documentation showed that staff were aware of the fall and the resulting injuries, but the event was not identified as neglect of care or reported as a facility-reported incident. Interviews with staff revealed that the Administrator, who also served as the Social Services Designee, Business Office Manager, Grievance Officer, and Abuse Prevention Coordinator, was unaware of quality-of-care concerns that would require reporting and investigating as facility-reported incidents. The Administrator admitted to not documenting incidents consistently and stated that no facility-reported incidents had been submitted to the State Survey Agency within the last six months, including the event involving the resident's fall and hip fracture. Another staff member confirmed that no reportable incidents had been submitted and described consulting with another staff member, who advised against reporting the event. Review of the resident's nursing progress notes indicated that after the fall, the resident exhibited significant injuries, including a large hematoma, a skin tear, and severe pain in the hip area. The initial response included canceling EMT transport and observing the resident overnight, with a portable X-ray ordered for the following morning. The next day, the resident was found in pain with a suspected broken hip, and EMS was called. The facility's policy required immediate reporting of alleged violations involving serious bodily injury, but no such report was made, and no investigation documentation was provided.