Failure to Investigate and Report Unwitnessed Fall Resulting in Major Injury
Penalty
Summary
The facility failed to initiate an abuse or neglect investigation after a resident experienced an unwitnessed fall that resulted in a major injury, specifically a fractured hip requiring surgery and hospitalization. Despite the severity of the incident, there was no documentation of a facility-reported incident, no investigation was completed, and the event was not reported to the State Survey Agency. Staff interviews revealed a lack of awareness and understanding of reporting requirements, with staff relying on corporate direction to determine whether to report and investigate such incidents. The facility also lacked prepared reports or tracking systems for monitoring incidents over time. Review of the resident's medical records indicated that the resident was found in pain with a broken hip and urine-soaked clothing, and was subsequently hospitalized and treated for additional complications, including blood clots. The facility's own policy required written procedures for reporting and investigating abuse or neglect, including analyzing occurrences and reporting results to government agencies. However, the facility did not follow these procedures, as no investigation or interviews were conducted, and no documentation was submitted for review. Staff admitted to not documenting or investigating unless instructed by corporate, and there was no evidence of compliance with the facility's abuse and neglect policy.