Failure to Timely Report Serious Injury Following Resident Fall
Penalty
Summary
The facility failed to ensure that all allegations involving abuse, neglect, or serious bodily injuries were reported immediately, but not later than 24 hours after the allegation was made. Specifically, an incident occurred in which a male resident with a history of impaired vision, right femur and tibia fractures, and osteoarthritis fell out of a shower chair while being transported back to his room. The incident resulted in a right distal shaft femur fracture, which was confirmed by hospital records. The resident required extensive assistance for mobility and had been receiving physical therapy following the injury. Despite the severity of the injury and the requirement to report such incidents to the State Agency, the facility did not submit a report regarding the fall and resulting fracture. The incident was documented internally, and the resident's family and medical provider were notified. However, the event was not reported to the State Agency as required by facility policy and state regulations. The omission was confirmed through interviews with facility staff, including the Abuse Coordinator, DON, and other nursing staff, who indicated that they either did not believe the incident met the criteria for reporting or were unaware of the reporting requirements. The facility's own Abuse Prohibition Policy mandates immediate reporting of all allegations and substantiated occurrences of abuse, neglect, or serious bodily injury to the state agency. In this case, the incident was not reported, and the failure to do so was attributed to the staff's interpretation of the event as non-suspicious and not indicative of neglect or abuse. The lack of timely reporting was further highlighted when a complaint was later filed by the resident, prompting an investigation.