Failure to Timely Self-Report Unwitnessed Fall With Injury to State Survey Agency
Penalty
Summary
The facility failed to timely submit a Facility Initiated Report and a five-day follow-up report to the State Survey Agency (SSA) for an unwitnessed fall with injury and subsequent left hand injury involving Resident #7. Nursing documentation dated 09/16/25 at 6:13 a.m. showed that Resident #7 reported falling into a wheelchair, with noted swelling, mild deformity, bruising, and pain rated 6/10 to the left hand. A facility complaint intake report dated 10/10/25 documented that Resident #7 had an unwitnessed fall on 09/16/25 resulting in a broken finger. Review of the SSA’s intake records showed no facility report was received on 09/16/25 for this unwitnessed fall with injury, and the SSA follow-up report indicated the facility’s follow-up was not completed until 12/04/25, 79 days after the fall. During interview, the DON stated that any fall with significant injury should have been reported right away and acknowledged that an in-house report to the state should have been made within two hours of the facility becoming aware of the unwitnessed fall on 09/16/25. This sequence of events demonstrates that staff did not report the unwitnessed fall with injury and the left hand injury for Resident #7 within the required timeframe, and the facility did not provide the mandatory self-initiated incident report or timely five-day follow-up report to the SSA as required.
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