Failure to Timely Report Resident Fall with Fracture
Penalty
Summary
The facility failed to report a resident's unwitnessed fall that resulted in a left hip fracture to the Department within the required 48-hour timeframe. The incident involved a resident with dementia and a history of falls and fractures prior to admission. The resident was found on the floor in a supine position at the end of the bed and complained of left hip pain. An X-ray confirmed an acute intertrochanteric femoral fracture. The fall was reported internally to the charge nurse and DON, but not to the Department as required by state law. Interviews with staff, including a licensed nurse, the DON, and a CNA, confirmed the details of the fall and the subsequent injury. Review of the medical record and incident reports corroborated the timeline and the nature of the injury. The failure to report the incident to the Department delayed the Department's investigation into the event.