Failure to Timely Report Unwitnessed Fall With Serious Head Injury
Penalty
Summary
The facility failed to ensure that an allegation of an injury of unknown source with serious bodily injury was reported immediately, or within two hours, to the Administrator as required by its abuse, neglect, exploitation, or misappropriation reporting policy. The policy specified that all suspected abuse, neglect, exploitation, misappropriation, or injuries of unknown source must be reported immediately to the Administrator and appropriate authorities, with “immediately” defined as within two hours for allegations involving abuse or resulting in serious bodily injury. For one resident, the Director of Nursing (DON) was notified around 7:00 a.m. by an LPN that the resident had been found on the floor unresponsive with a hematoma to the right side of the head and a laceration to the back of the head, but the DON did not convey the seriousness and unwitnessed nature of the incident when notifying the Corporate Administrator. The resident involved had been admitted with diagnoses including unspecified atrial fibrillation, right-sided rib fractures, type 2 diabetes mellitus without complications, stroke, hypertension, and age-related osteoporosis without current pathological fracture. A recent Quarterly MDS showed a BIMS score of 13 (no cognitive impairment), supervision or touching assistance needed for bed mobility, transfers, and toileting, partial/moderate assistance for bathing, no functional ROM limitations, and no recent falls. On the morning of the incident, the LPN found the resident lying face down on the floor, unresponsive, with visible head injuries and blood on the floor, and sent the resident to the emergency room, where the resident later expired. The DON notified the Corporate Administrator at 9:15 a.m. but only reported that the resident had a fall, omitting that it was unwitnessed and resulted in serious bodily injury, and the Corporate Administrator confirmed he should have been notified immediately of the unwitnessed fall with serious bodily injury.
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