F0609

D

Failure to Timely Report Fall-Related Serious Injuries to Authorities

Desoto, Texas Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report an alleged incident of abuse/neglect and serious injury to the appropriate authorities as required by regulation and by its own policies. A cognitively impaired, Spanish‑speaking male resident with Alzheimer’s dementia, non‑Alzheimer’s dementia, anemia, HTN, diabetes, and on antipsychotic and antidepressant medications was admitted with severe cognitive impairment (BIMS score 00) and required supervision or assistance with mobility, transfers, toileting, and ADLs. His care plan identified him as at risk for falls and wandering, with interventions including frequent visual checks, redirection, and assistance with standing and moving. The facility’s written policy required that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation be reported to the Administrator/Abuse Coordinator and, when reportable, to the State Survey Agency and other authorities within 2 hours if involving abuse or serious bodily injury, or within 24 hours otherwise.

On the date of the incident, according to a late entry progress note by the DON, the resident was reported to have been roaming in and out of rooms and requiring frequent redirection. At approximately 7:00 a.m., when redirected from a room, he became aggressive and attempted to swing and hit the nurse, lost his balance, and fell against a handrail on his left side. The primary nurse reportedly noted a small abrasion to the left temple area, with no other injuries observed at that time, and documented that the resident was ambulatory and functioning at baseline after the fall, with plans for frequent monitoring post‑fall. The facility’s fall management policy required assessment for injury, investigation of the reason for the fall, completion of an incident/accident report, and notification of the physician and family when a fall occurs.

Later that same day, the resident’s family requested hospital evaluation for change of condition with nausea and vomiting, and the resident was sent to the hospital, placed on leave of absence, and medications were put on hold. Hospital records documented that the resident was admitted with a chief complaint that he had fallen, and he was found to have right 6th and 7th lateral rib fractures, a right adrenal hematoma, and a grade 3 liver laceration involving segments 5 and 8. The hospital nurse informed the DON that the resident had fallen at the facility earlier that day, had an abrasion to the cheek, a bruised liver, and rib fractures. The Administrator and DON acknowledged they did not report the incident to the State agency (HHSC) or other required authorities. The DON stated she did not submit a report because, after her assessments and interviews, she ruled out abuse and neglect, and the Administrator stated he did not report because the fall was witnessed and the family transported the resident to the hospital at their discretion. This failure to report an allegation involving a fall with serious bodily injury within the required timeframes constituted the cited deficiency.