LOS ANGELES, CA - State inspectors cited Overland Terrace Healthcare & Wellness Centre after discovering the facility failed to report a serious fall that sent a dementia patient to the emergency room with a head injury requiring sutures.
Unreported Emergency Room Transfer
The violation centered on a February 28, 2025 incident involving a 71-year-old resident with dementia and a history of falls. According to inspection records, the resident climbed out of bed and experienced an unwitnessed fall that resulted in a significant laceration to his left eyebrow. The injury was severe enough that nursing staff had to apply pressure to stop the bleeding and used adhesive bandages to close the wound before paramedics arrived to transport the resident to Greater Los Angeles Community Hospital via emergency services.
Hospital records confirmed the resident sustained a left eyebrow laceration from the unwitnessed fall and required sutures. Medical staff scheduled the resident to return to the emergency department five days later for suture removal. When inspectors observed the resident several days after the incident, he displayed dark discoloration under his left eye and visible sutures on his eyebrow.
Breakdown in Communication and Reporting
The inspection revealed a concerning pattern of miscommunication among facility leadership regarding the severity of the injury. The Registered Nurse Supervisor, who responded to the incident and applied emergency care, acknowledged to inspectors that she failed to report the unwitnessed fall with significant injury to the California Department of Public Health (CDPH). She stated she only notified the Director of Nursing about the incident.
The Director of Nursing admitted during interviews that she was aware of all the details: the fall, the eyebrow laceration, the emergency room transport via 911, and the application of medical adhesive strips. However, she claimed she did not report the incident to state authorities because the nurse supervisor had described the injury as merely an "abrasion" rather than a laceration. The Director of Nursing later acknowledged that she should have reported the unwitnessed fall with significant injury to CDPH within 24 hours, as required by regulations.
Administrator's Medical Knowledge Gap
Perhaps most concerning was the administrator's response during the inspection interview. The administrator confirmed receiving notification about the fall and emergency transport on the day of the incident but stated he did not report it to CDPH because he believed the resident had not sustained a "significant injury." Despite being aware that nursing staff had applied emergency wound care and called 911 for transport, the administrator revealed he lacked basic medical knowledge, stating he had no medical training and could not define what constitutes a laceration.
Medical Significance of Head Injuries in Dementia Patients
Head injuries pose particular risks for residents with dementia, especially those with a documented history of falls. When a head impact is severe enough to cause bleeding and require emergency medical attention, it can indicate potential complications including traumatic brain injury, which can worsen cognitive decline in dementia patients. The need for sutures indicates the wound penetrated through multiple layers of tissue, creating infection risks and requiring proper medical monitoring during the healing process.
Unwitnessed falls present additional medical concerns because healthcare providers cannot assess whether the resident lost consciousness or experienced other complications during the incident. The fact that this resident required immediate pressure application to control bleeding demonstrates the injury's severity and the potential for complications if not properly treated.
Regulatory Requirements and Industry Standards
Federal regulations require nursing homes to report serious incidents, including falls resulting in significant injuries, to state health departments within 24 hours. This reporting requirement ensures appropriate oversight and helps protect vulnerable residents. Falls resulting in emergency room transfers, especially those requiring medical intervention like sutures, clearly meet the threshold for mandatory reporting.
The facility's own policy, reviewed during the inspection, explicitly states that "unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing." This policy aligns with standard nursing home practices designed to maintain transparency and ensure proper medical follow-up for injured residents.
Additional Issues Identified
The inspection documented concerns about the facility's assessment and documentation practices for the resident, who had been readmitted with diagnoses of history of falling and unspecified dementia. Records showed the resident's cognitive abilities were moderately impaired and he required moderate to maximum assistance with activities of daily living, yet the fall prevention measures in place proved inadequate to prevent this serious incident.
The violation highlights systemic issues in incident reporting and staff training at the Los Angeles facility, particularly regarding the medical assessment of injuries and understanding of regulatory reporting requirements for patient safety incidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Overland Terrace Healthcare & Wellness Centre, Lp from 2025-03-06 including all violations, facility responses, and corrective action plans.
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