Late Submission of Five-Day Written Investigation Report Following Resident Falls
Penalty
Summary
The facility failed to complete and submit a five-day written investigation report regarding an allegation of potential neglect for one resident. The facility's policy requires the administrator or designee to report the results of an investigation within five working days of an incident. Record review showed that a resident experienced multiple falls over several days, resulting in a right wrist fracture. Documentation indicated that the resident was found on the floor, had been using a cane instead of a walker, and was not wearing non-skid socks. Although assessments were completed and the interdisciplinary team reviewed the falls, the facility submitted the required five-day written report two days late, on the seventh day after the incident, rather than within the mandated five-day period. This delay was confirmed by the Regional Director of Operations.