Failure to Investigate and Report Serious Injury After Fall
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and document an allegation of neglect after a resident sustained serious injuries related to a fall. The resident was an elderly male with severe cognitive impairment (BIMS score 00), Spanish-speaking only, with diagnoses including anemia, hypertension, diabetes mellitus, Alzheimer’s dementia, and non-Alzheimer’s dementia. His care plan identified impaired functional abilities, need for assistance with ADLs, and risk for falls and wandering, with interventions such as assistance with mobility and frequent visual checks. On the date of the incident, a late-entry nursing note documented that the resident had been roaming in and out of rooms, became aggressive when redirected, attempted to swing at the nurse, lost his balance, and fell against a handrail, sustaining a small abrasion to the left temple; he was noted to be ambulatory and at baseline afterward. The resident was later sent to the hospital for a change of condition with nausea and vomiting per family request, and the progress note documented the transfer but did not reference the earlier fall as a cause. Hospital records showed that he was admitted with a chief complaint of a fall and 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, and he was admitted for trauma-related monitoring and pain control. The facility’s records and interviews revealed that the LVN who witnessed the fall did not report the incident to the Administrator, did not notify the physician, and did not notify the resident’s family member at the time of the fall. Interviews with the Administrator and DON confirmed that, after being notified by the hospital that the resident had sustained serious internal injuries and fractures from a fall that occurred at the facility, they did not initiate a timely, thorough investigation at that time. The Administrator acknowledged he had not investigated the incident when first notified of the hospitalization and injuries. The DON stated she did not investigate when first notified that the resident was in the hospital for a fall, despite knowing of the bruised liver and fractured ribs. The facility had an Abuse, Neglect and Exploitation and Misappropriation of Resident Property Internal Investigation Guidelines policy requiring timely investigation of all allegations of abuse, neglect, and exploitation, but there was no evidence that such an investigation was promptly initiated and documented when the serious injuries and unreported fall were first identified.
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