Failure to Timely Report Suspected Neglect and Injury After Resident Fall
Penalty
Summary
The facility failed to report a fall with suspected negligence and significant injury within the required time frame for one resident. According to the facility's own policy, allegations involving neglect or mistreatment that result in serious bodily injury must be reported to state and local authorities within two hours. In this case, a resident fell from an elevated bed after being left unsupervised by a CNA. The incident occurred late in the evening, and the resident subsequently experienced increased pain, prompting an x-ray order for suspected fractures. The resident died the following morning. Despite the serious nature of the incident, the facility did not submit an initial report to the Department of Licensing and Certification as required. Instead, a final report was submitted nearly two days after the fall, and there was no evidence of an initial, timely notification. The deficiency was confirmed through interviews, record reviews, and policy examination, which showed the facility did not adhere to its own reporting requirements following the incident.