Failure to Timely Report Serious Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of an incident involving a resident who experienced an unwitnessed fall resulting in a left femoral fracture. According to facility policy and regulatory requirements, all allegations of abuse, neglect, or injuries of unknown source that result in serious bodily injury must be reported to the New York State Department of Health immediately, but not later than two hours after the facility becomes aware. In this case, the resident, who had severe cognitive impairment and required supervision and assistance with mobility, was found on the floor near their bed in pain and holding their left thigh. The resident reported to staff that they had rolled off the bed and fallen, and was subsequently sent to the hospital where a left femoral fracture was diagnosed. Despite the facility becoming aware of the injury upon the resident's return from the hospital, the incident was not reported to the Department of Health until the following day, exceeding the required reporting timeframe. Interviews with facility leadership confirmed that the injury should have been reported within two hours of the facility learning about the fracture, but the report was delayed until confirmation of the injury was received. This delay in reporting did not comply with both facility policy and state regulations regarding the timely reporting of serious injuries of unknown origin.