Failure to Timely Report Serious Injury Following Unwitnessed Fall
Penalty
Summary
The facility failed to ensure timely reporting of an incident involving a resident who experienced an unwitnessed fall resulting in a laceration and an acute humeral neck fracture. According to the facility's policy, all alleged violations involving abuse, neglect, or injuries of unknown source must be reported to the New York State Department of Health immediately, but not later than 2 hours if the event involves abuse or results in serious bodily injury, or within 24 hours if it does not. In this case, the incident was not reported as required. The resident, who had diagnoses including dementia and breast cancer and was assessed as severely cognitively impaired, was found on the floor with a bleeding laceration and later diagnosed with a fracture after returning from the emergency room. The Director of Nursing and the Administrator both acknowledged responsibility for reporting such incidents but stated that the event was not reported because they believed the fracture was directly correlated with the fall and not of unknown origin. Documentation showed that the resident had impaired vision and bony demineralization, which staff believed could have contributed to the injury. Despite these findings, the incident and resulting injury were not reported to the Department of Health as required by regulation and facility policy.