Failure to Report Serious Injury from Resident Fall to State Agency
Penalty
Summary
The facility failed to notify the State Agency of both the initial and final reports after a resident was emergently transferred to a local hospital and diagnosed with an acute and displaced right femoral neck fracture. The resident is an adult female with medical diagnoses including a prior left femur fracture, anxiety disorder, bipolar disorder, lupus, and dependence on hemodialysis. Her MDS showed a BIMS score of 13/15, indicating she was cognitively intact. The resident reported that she fell in the bathroom at 5:15 AM while getting ready for the day, with no staff present at the time of the fall, and that paramedics picked her up from the floor and transported her to the hospital. Hospital documentation from the same morning described the resident as very tearful and in severe right hip and thigh pain, with CT and X-ray imaging confirming a basicervical fracture of the right femoral neck and an acute, displaced right femoral neck fracture. During interviews, the DON stated that the incident was not reported to the State Agency because they only report unwitnessed falls and believed this fall was observed by the nurse on the floor. The administrator stated that, because the resident had a pathological fracture, they believed it did not need to be reported to the State Agency and expressed uncertainty about the policy. The facility’s written fall prevention and management policy, however, requires that all incidents and accidents with serious physical injury be reported to the State Agency within 24 hours, with a full written investigative report submitted within seven days of the incident.
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