Failure to Timely Report Serious Injury Following Unwitnessed Fall
Penalty
Summary
The facility failed to ensure timely reporting of an incident involving a resident who was found on the floor bleeding from the nostrils and later diagnosed with a nasal bone fracture. According to the facility's policies and state regulations, any incident involving serious bodily injury must be reported to the State Agency within two hours of becoming aware of the event. In this case, the resident was discovered on the floor at approximately 7:03 AM, was assessed by nursing staff, and subsequently transferred to the hospital for evaluation. The initial assessment by facility staff did not identify a fracture, and the incident was not reported to the State Agency at that time. The resident involved had a history of cerebral ischemia, cerebrovascular accident, and severe cognitive impairment. The facility's Director of Nursing and Administrator both stated that they were not aware of the nasal fracture until three days after the incident, upon receiving the hospital discharge summary and x-ray results. Despite the discovery of the fracture, the facility did not report the incident to the New York State Department of Health, as required by regulation, because they believed the reporting timeframe had already passed and did not consider the event to be of unknown origin or abuse. The facility's own policies require that all incidents resulting in serious bodily injury be reported within two hours, regardless of when the injury is confirmed. The investigation conducted by the facility concluded that there was no abuse, mistreatment, or neglect, but the failure to report the incident in a timely manner constituted a deficiency in compliance with state and federal regulations.