Failure to Submit Timely Investigative Report After Resident Injury
Penalty
Summary
The facility failed to submit a required investigative report to the State Agency within 5 working days following a significant injury sustained by a resident. According to the facility's policy, any incident resulting in serious bodily injury must be followed by a detailed investigative report submitted to the state within the specified timeframe. In this case, a resident with a diagnosis of metabolic encephalopathy was admitted to the facility and subsequently experienced an unwitnessed fall, resulting in a fractured nasal bone and lacerations requiring stitches. The incident was documented, and the resident was transported to the hospital for treatment. Although the facility notified the State Agency within 2 hours of becoming aware of the resident's significant injury, there was no evidence that a follow-up investigative report was submitted within 5 business days as required. The Director of Nursing confirmed that the follow-up report was not sent, despite the policy and regulatory requirements. This omission constituted a failure to comply with state regulations regarding timely reporting of incidents involving serious injury.