Failure to Investigate Unusual Occurrence After Fall and Worsening Subdural Hematoma
Penalty
Summary
The deficiency involves the facility’s failure to identify and investigate an unusual occurrence related to a resident with a known subdural hematoma and history of repeated falls. The resident was admitted with multiple diagnoses including dementia, glaucoma, repeated falls, abnormal gait and mobility, and a subdural hematoma. On 1/21/26, a Change in Condition Evaluation documented that around 5:00 AM the resident was found sitting on the floor at the foot of her bed, unable to state what happened, denying head injury and pain, with no new skin tears, normal PERRLA, intact upper and lower extremity movement, and refusal of vital signs at that time. The DON later acknowledged awareness of this fall, the resident’s subsequent transfer to the hospital on 1/31/26, and neurosurgery performed that same day, but stated she did not formally investigate the case as an unusual occurrence. In the days following the fall, the resident’s family member reported noticing the resident becoming lethargic, less responsive, more unsteady, and not eating well, and stated she had to beg staff to transfer the resident to the hospital for evaluation. Hospital records from 1/31/26 documented that the daughter had been notified of the 1/21 fall and had observed the resident becoming more unsteady, lethargic, and with decreased intake over several days, and that the resident presented with altered mental status and less mobility over the past weeks, especially in the last couple of days. The hospital identified a left holohemispheric chronic subdural hematoma and recommended burr hole drainage. During interviews, the DON stated she did not formally investigate the case and, in retrospect, believed she should have, and the Medical Director agreed that the facility should have formally investigated the case to determine if nursing practices needed improvement. Review of the facility’s Unusual Occurrence Reporting policy showed it addressed reporting unusual occurrences but did not address formal investigation to identify deficiencies and develop interventions.
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