Failure to Report Unwitnessed Falls to State Agency and Incident Log
Penalty
Summary
The deficiency involves the facility’s failure to report unwitnessed falls to the State Survey Agency within 24 hours and to enter these incidents into the facility’s incident reporting log for two residents. One resident, admitted for nursing care and rehabilitation after a fall requiring hip and femur surgery, was alert, oriented, and able to make their needs known. This resident reported attempting to transfer into a chair at night, falling to the floor, and being unable to reach the call light, then crawling to the door to yell for help. A nurse’s progress note documented hearing the resident calling for help, finding the resident on the floor, and noting that the wheelchair and walker were far from the fall position, consistent with the resident’s report of having pulled themself to the door. The resident was assisted back to bed, had a hip x-ray, and the fall was documented by the provider and reviewed by the interdisciplinary team, but there was no corresponding entry in the facility’s incident reporting log and no report submitted to the State Survey Agency for this unwitnessed fall. The second resident, admitted with dementia, chronic kidney disease, and pressure ulcers for respite nursing and palliative care, was cognitively impaired but able to make needs known and required staff assistance with ADLs. A collateral contact stated the resident was bedridden, questioned how the resident could have fallen out of bed, and expressed concern that staff could not say how long the resident had been on the floor. A nursing note documented that the resident was found on the floor next to the bed, was unable to verbalize how the fall occurred, and was returned to bed via Hoyer lift with two-person assist, with no injuries identified. The provider and family were notified, and the fall was reviewed by the interdisciplinary team with care plan updates, but the incident was not entered into the facility’s incident reporting log and was not reported to the State Survey Agency. Staff later stated that both residents’ falls had been reported in the internal system but were not added to the State reporting log, resulting in the failure to meet the reporting requirements under WAC 388-97-0640(7)(a)(b)(i).
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