Failure to Timely Report Major Injury Fall
Penalty
Summary
The facility failed to report a fall with major injury involving a resident to the State Survey Agency within the required two-hour timeframe. According to the facility's policy, any alleged violations involving abuse or resulting in serious bodily injury must be reported immediately, but not later than two hours. The incident involved a resident with severe cognitive impairment and a history of Alzheimer's disease, dementia, and a previous left femur fracture. The resident, who was dependent in most self-care and mobility activities, was observed to rise from her wheelchair and fall to the floor, sustaining an injury to her left femur. Staff immediately assessed the resident, contacted the Medical Director and family, and arranged for x-rays and pain management. However, the incident, which occurred in the early evening, was not reported to the state until the following day. Interviews with staff and the administrator confirmed that the reporting did not occur within the required timeframe, despite the facility's policy clearly outlining the two-hour reporting requirement for such incidents.