Failure to Report and Investigate Resident Fall with Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source—were reported and investigated in accordance with state law and facility policy. Specifically, for one resident with multiple diagnoses including dementia, Alzheimer's disease, and muscle weakness, there was an unwitnessed fall resulting in a left hip fracture. The clinical record and progress notes indicated that the fall was documented, the resident was assessed, and sent to the hospital for further evaluation and treatment. However, there was no evidence that a provider investigation report or the required 5-day investigation report was submitted to the state survey agency as mandated. Interviews with the DON and the current Administrator revealed that the transition between administrators contributed to the lack of clarity regarding whether the required investigation report was submitted. The DON was unsure if the previous Administrator had completed the process, and the current Administrator could not locate the 5-day investigation report in the facility's records. The facility's own policy required reporting all such incidents to the administrator or designee and to the state agency, but this was not followed in this case.