Failure to Timely Submit Investigation Summary After Resident Fracture
Penalty
Summary
The facility failed to submit a summary of investigation of an alleged unusual incident/injury report to the Department within five working days, as required, following a fracture incident involving a resident. The resident, who was admitted under hospice care with multiple diagnoses including senile degeneration of the brain, Parkinson's disease with dyskinesia, unspecified dementia, COPD, depressive disorder, and a right femur fracture, was found sitting on the floor with no visible injury noted upon assessment. Subsequently, the resident complained of right hip pain and an X-ray revealed a subacute fracture of the right femoral neck. Despite being aware of the requirement, the DON acknowledged during interviews that she forgot to submit the summary of investigation for the incident. The facility's policy requires prompt initiation and documentation of investigations for accidents or incidents, but this was not followed in this case. The lack of timely submission of the investigation summary meant that the Department was not informed within the mandated timeframe following the incident.