Failure to Timely Submit 5-Day Investigation Reports to State Agency
Penalty
Summary
The facility failed to submit investigation reports to the State Agency within the required 5 working days for two residents who experienced significant incidents. For one resident, after being transferred onto a bed with a Hoyer lift by a nurse aide without assistance, the resident sustained a right arm injury resulting in pain and swelling. The incident was reported internally, and the resident was assessed and treated, but the investigation summary was not sent to the State Agency until several days after the required timeframe. Facility policy mandates that such reports be sent within five working days, but this was not followed. In another case, a resident fell while walking in the hall, resulting in severe pain and a hospital visit. The incident was reported to Adult Protective Services on the same day, but the 5-day investigation report was not sent to the State Agency until the sixth day. In both cases, interviews with the Administrator confirmed that the reports were not submitted within the required timeframe, constituting a failure to respond appropriately to alleged violations as required by regulation.