Failure to Report Fall With Major Injury to State Health Department
Penalty
Summary
The deficiency involves the facility’s failure to report a fall with major injury to the state health department as required by its own policy and state regulatory guidance. The facility’s document titled “Long Term Care Reportable Incidents - Regulatory Requirements,” dated 06/28/22, stated that all reports to the Department must be made within 24 hours and that incidents resulting in fractures, injuries requiring hospital treatment, a physician’s diagnosis of closed head injury or concussion, or head injuries requiring more than first aid must be reported. Resident #97’s November 2025 MAR showed the resident was on chronic anticoagulation therapy with Warfarin Sodium for atrial fibrillation and thrombophilia. A nurse’s note dated 12/01/25 documented that a head-to-toe assessment after a fall revealed bleeding from the frontal forehead and the left side of the skull, and the resident was sent to the emergency room via ambulance. A neurosurgery consult progress note dated 12/02/25 documented that the resident, with atrial fibrillation on Warfarin, had a ground-level fall at the facility and was diagnosed with a T12 vertebral fracture and bilateral subdural hematomas. An MDS dated 12/05/25 confirmed the resident’s diagnoses, including atrial fibrillation, heart failure, and thrombophilia. During interviews, the ADON stated that they or the DON were responsible for reporting incidents other than abuse to the state health department. The DON stated that the fall on 12/01/25 was not reported because they did not consider it a reportable incident, asserting there were no stitches or major injury and that the T12 fracture and bilateral subdural hematomas were not considered major injuries since the resident was discharged with no treatment recommendations. The DON later acknowledged, after reviewing the LTC reportable incidents document, that the incident should have been reported.
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