Failure to Timely Report Serious Injury Incident to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours, to the State Survey Agency after the allegation was made, as required by facility policy and state regulations. On 07/28/2025, a resident with a history of osteoarthritis of the hip and previous fractures fell from the bed to the floor during care provided by a Certified Nursing Assistant. The resident sustained a laceration to the head and fractures to the right hand and left middle finger, and was subsequently transferred to the hospital for evaluation and treatment. Despite the incident resulting in serious bodily injury, the facility did not report the event to the New York State Department of Health until 07/31/2025, approximately three days after the incident occurred and the Administrator was made aware. The Director of Nursing, who was responsible for reporting such incidents, stated that they delayed reporting in order to gather more details, inadvertently missing the required two-hour reporting window. Facility policy clearly required immediate reporting of such incidents, but this protocol was not followed in this case.