Failure to Timely Report and Investigate Serious Injuries
Penalty
Summary
The facility failed to timely report allegations involving serious bodily injury and did not complete investigations within the required timeframes. In one incident, a resident sustained second-degree burns with clustered blisters on the left thigh after spilling hot coffee during breakfast. The incident occurred on 1/14/25, but the facility did not begin its investigation until 1/16/25 and did not report the incident to the State Survey Agency until 1/21/25, which exceeded the required two-hour reporting window for serious injuries. Additionally, the facility did not complete and submit the investigation report within the mandated five-day period, as the closure was not reported until 1/29/25. In another case, a resident was found with bruising and diagnosed with a displaced clavicle fracture and multiple rib fractures. The facility became aware of these injuries on 2/10/25, but did not submit the initial Facility Reported Incident (FRI) to the Office of Health Care Quality until the following day, missing the two-hour reporting requirement. The resident, who had moderate cognitive impairment and spoke Bengali, denied falling or being abused, and staff reported no witnessed falls or incidents. Despite the injuries being of unknown origin, the facility did not adhere to the required reporting timeframe.