Failure to Promptly Investigate and Report Resident Fall
Penalty
Summary
The facility failed to conduct a prompt and thorough investigation following a fall experienced by a resident who was assessed as severely cognitively impaired and had recently undergone surgical repair for a right hip dislocation. The fall, which occurred on 04/06/2025, was not reported by the responsible licensed nurse at the time of the incident, and nurse management was not notified. Risk management procedures and immediate interventions were not implemented as required by facility policy. The incident only came to light when the resident developed new onset pain, prompting an investigation on 04/14/2025, which revealed a dislocation of the right hip arthroplasty without acute fracture. Record review and staff interviews confirmed that the facility's policy for investigating and reporting accidents and incidents was not followed. The nurse supervisor/charge nurse did not promptly report the accident to the administrator or initiate and document an investigation at the time of the fall. The lack of timely notification and intervention was acknowledged by the Director of Nursing Services, who stated that a thorough investigation should have been conducted and documented immediately after the fall.