Failure to Timely Report Fall with Major Injury
Penalty
Summary
The facility failed to report a fall with major injury to the State Survey Agency within 24 hours as required. A resident with diabetes and kidney failure, admitted in December 2023, sustained a fall while working with physical therapy. Following the fall, the resident complained of pain, and x-rays were ordered. The next day, the provider ordered the resident to be sent to the hospital for further evaluation, where multiple fractures in the right leg were identified. Despite these findings, the former Director of Nursing Services (DNS) did not file a Facility Reported Incident (FRI), believing it was unnecessary since the injuries were not considered serious bodily injury according to her interpretation of the FRI form. The current DNS also acknowledged that an FRI was not submitted for the incident.