Other·May 23, 2023

Title 22 § 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. The facility failed to report to the State Survey Agency an unusual occurrence that occurred on 3/27/2023, where Resident 1, had an unwitnessed fall and sustained an injury. As a result, there was a delay of an onsite inspection by the SSA to ensure the safety of Resident 1 and to ensure the unusual occurrence was investigated timely. On 4/14/2023, the Department of Public Health (State Survey Agency-SSA) made an unannounced visit to the facility to investigate a complaint related resident neglect and quality of treatment and care of the Resident 1 A review of Resident 1's Admission Record indicated that the facility admitted Resident 1 on 3/16/2023 with diagnoses including history of motor vehicle accident; resulting for sacrum (bone at the bottom of the spine and lies between the fifth segment of the spine and the tailbone) and pubis (part of the pelvic [hip] bone) fracture (a break, crack or crush injury of the thigh bone), and traumatic subdural hemorrhage (bleed inside the head). Resident 1 was discharged to the general acute hospital (GACH) on 3/28/2023. A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care-screening tool), dated 3/22/2023, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was intact and requiring one-person physical assistance from staff for activities of daily livings (ADLs-bed mobility, dressing, toilet use and personal hygiene). A review of Resident 1's SBAR (situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members. Also, being used as documentation for any changes of condition) dated 3/27/2023, indicated Resident 1 had a fall incident. A review of Resident 1's Progress Notes, dated 3/27/2023 at 6:06 a.m., indicated that Resident 1 was found on the floor, unwitnessed on her left side inside the bedroom with a skin tear on left wrist. A review of Resident 1's Progress Notes, dated 3/27/2023 at 12:58 p.m., indicated Resident 1 was complaining of pain on the left arm and back. A review of Resident 1's Physician Order, dated 3/27/2023, indicated Resident 1 had an order for a stat (immediate) order of the left arm, chest and lumbar (spine; lower back) x-rays (electromagnetic energy that produced images of internal tissues, bones and organs on film or digital media). A review of Resident 1's X-ray results, dated 3/27/2023, indicated lumbar compression fracture and displaced fracture of the distal radius (bone located between the wrist and the forearm). A review of Resident 1's Progress Notes, dated, 3/28/2023 at 9:00 p.m., Resident 1 was transferred to GACH for further evaluation of the status post fall fracture. A concurrent record review and interview with the Facility Administrator-also a registered nurse (FA) on 4/25/2023 at 1:48 p.m., FA stated and verified that Resident 1's incident was not reported. A review of Facility's policy and procedures titled, "Unusual Occurrence Reporting," revised 12/2007, indicated as required by federal and state regulations, the facility will report unusual occurrences or other reportable events which affect the health, safety, or welfare of their residents, employees or visitors. The facility failed to report to the State Survey Agency an unusual occurrence that occurred on 3/27/2023, where Resident 1, had an unwitnessed fall and sustained an injury. As a result, there was a delay of an onsite inspection by the SSA to ensure the safety of Resident 1 and to ensure the unusual occurrence was investigated timely. The above violations had a direct relationship to the health, safety, and security of Resident 1.