Failure to Report Resident Fall with Injury to State Authorities
Penalty
Summary
The facility failed to comply with Federal, State, and local laws and professional standards when it did not report an unusual occurrence involving a resident to the California Department of Public Health (CDPH) as required by state regulation (22 CCR S 72541). The incident involved a resident with multiple diagnoses, including muscle weakness, who experienced an unwitnessed fall. The fall resulted in a 2 cm laceration with moderate bleeding to the back of the resident's head. Licensed nurses responded to the incident after hearing a loud noise, found the resident on the floor, and noted active bleeding. Emergency services were called, and the resident was transported to the hospital for evaluation and returned to the facility the following day. During an interview, the Director of Nursing (DON) confirmed that the incident was not reported to CDPH, stating the belief that the injury was not significant enough to require reporting. However, the facility's own policy and procedure for Unusual Occurrence Reporting, as well as state regulations, require reporting of such events that affect the health, safety, or welfare of residents. The failure to report this incident constituted noncompliance with applicable laws and professional standards.