Failure to Timely Report Serious Injuries from Unwitnessed Falls
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made, to the administrator and the State Survey Agency as required by regulation. Specifically, two residents who experienced unwitnessed falls resulting in serious injuries were not reported to the State Survey Agency. In both cases, the facility did not interpret the incidents as requiring immediate reporting, as the source of the injury was considered known due to the residents being found on the floor and able to communicate that they had fallen. One resident, an elderly male with multiple diagnoses including a prior right tibial fracture, muscle weakness, cognitive impairment, and a high risk for falls, was found on the floor of his room at night. He was assessed, transferred to bed, and later noted to have blood in his Foley catheter bag and pain in his right hip. He was subsequently sent to the hospital, where a fractured hip and blood loss were identified. Despite the unwitnessed nature of the fall and the serious injury, the incident was not reported to the State Survey Agency as required. A second resident, an elderly female with severe cognitive impairment, functional limitations, and a high fall risk, was found on the floor during CNA rounds, complaining of severe pain in her hip and leg. She had a skin tear and bruising, and EMS was called to transfer her to the hospital, where a fractured hip was diagnosed. The facility did not report this incident to the State Survey Agency, as staff believed the cause of the injury was known. Interviews with facility staff and review of facility policy confirmed that unwitnessed falls with serious injury were not reported if the resident could communicate that they had fallen, contrary to regulatory requirements.