Failure to Timely Report Serious Bodily Injury to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report a known serious bodily injury to the South Dakota Department of Health (SD DOH) within the required 2-hour timeframe. A resident slipped from her wheelchair onto her left hip and complained of left hip pain in the afternoon. A portable X-ray was obtained, and by early evening a registered nurse documented that the X-ray results showed a left intertrochanteric femur fracture, and the results were faxed to the physician. The resident’s family initially delayed transfer to the emergency department (ED) while they discussed options, and the resident was ultimately transferred to the ED the following morning, admitted to the hospital, and later died. The facility’s Facility Reported Incident (FRI) to SD DOH was not submitted until late that same morning. Interviews and policy review showed that the DON and administrator were responsible for reporting incidents to SD DOH and were aware that a confirmed hip fracture, even when diagnosed via portable X-ray in the facility, constituted a serious bodily injury that must be reported within two hours of the allegation or identification. The DON stated that reporting after outside medical attention was to occur within 24 hours, but also acknowledged that a confirmed hip fracture required reporting within two hours. The administrator reported he believed that because the resident did not receive outside medical attention immediately after the fall, the incident fell under the 24-hour reporting requirement. The facility’s Abuse and Neglect policy specified that any allegation involving serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. Despite this policy and knowledge that a hip fracture is a serious bodily injury, the facility did not report the incident to SD DOH within the required 2-hour timeframe after the fracture was confirmed.
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