Failure to Report Unwitnessed Injury of Unknown Origin and Resident Death to CDPH
Penalty
Summary
The facility failed to report an injury of unknown origin and subsequent death of a resident to the California Department of Public Health (CDPH) as required by regulation and facility policy. The resident had diagnoses including schizophrenia, glaucoma, and hypertension, and an MDS assessment showed severe cognitive impairment, with the resident sometimes able to understand and be understood, and requiring supervision or touch assistance for transfers between bed and chair or wheelchair. On the evening of the incident, a CNA walking past the resident’s room found the resident face down on the floor. An LVN assessed the resident and determined he was unresponsive, without a pulse, not breathing, and with blood coming from his nose. Paramedics arrived, took over resuscitation efforts, and pronounced the resident deceased shortly thereafter. The DON stated she was informed of the resident’s injury and death by an unidentified nurse but did not report the incident to CDPH because she did not consider it an unusual occurrence. She indicated that, based on her investigation, the resident may have become unresponsive in bed and fallen to the floor, injuring his nose, but acknowledged the incident was unwitnessed and the exact cause could not be determined. The facility’s Abuse Investigation and Reporting policy, revised 7/2017, required that all reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source be promptly reported to local, state, and federal agencies, including the state licensing/certification agency. The policy further required that alleged violations involving abuse or resulting in serious bodily injury be reported immediately, but not later than two hours, and other alleged violations within 24 hours. Despite these requirements, the facility did not report this unwitnessed injury of unknown origin and death to CDPH.
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