Failure to Submit Required Five Day Report After Resident Falls and Injury
Penalty
Summary
The facility failed to complete and submit a Five Day Report to the State Agency following allegations of neglect involving a resident who experienced multiple falls and sustained a right femoral neck fracture. The resident, who had diagnoses including cardiomyopathy, type 2 diabetes mellitus, unspecified dementia, hypoxemia, and atherosclerotic heart disease, was admitted and subsequently fell twice shortly after admission. The falls were documented in the Facility Reported Incident, but the times of the falls were not recorded. The resident complained of pain, which led to the diagnosis of a right femoral neck fracture, and was then discharged to the hospital. A review of the resident's electronic health record revealed no evidence that the facility conducted an investigation into the falls or the resulting fracture. During an interview, the DON stated that no investigation was completed because the resident did not return to the facility after hospitalization. The DON acknowledged awareness of the requirement to submit a Five Day Follow-Up report to the State Agency but did not do so in this case.