Late Submission of Investigative Findings for Reportable Incident
Penalty
Summary
Facility staff failed to report the investigative findings of a reportable incident involving a resident who experienced an unwitnessed fall in the bathroom, resulting in a humerus fracture. The incident was initially reported to the State Survey Agency, but the required investigative findings were not submitted within the mandated five working days. The findings were ultimately reported one day after the submission deadline. Staff interviews revealed that the responsibility for submitting reportable incidents had shifted between staff members due to administrative changes, and the staff member responsible at the time was aware of the delay but could not recall the reason for it. Documentation confirmed that the delay in reporting was recognized internally, and the staff member responsible had reported the issue to the QAPI committee. The deficiency was identified through review of facility records, interviews with staff, and examination of the timeline of incident reporting. The report specifically notes that the late submission of investigative findings was limited to this incident, with no additional late reports identified during a retrospective audit.