Failure to Timely Report Suspected Abuse/Neglect Incident Involving Fractures
Penalty
Summary
The facility failed to ensure that an alleged violation involving potential abuse, neglect, exploitation, or mistreatment was reported immediately to the State Survey Agency and that investigative findings were submitted within five working days, as required by facility policy and regulation. The facility’s policy, revised in October 2025, requires that allegations involving abuse or serious bodily injury be reported not later than two hours after the allegation is made, and that investigative findings be submitted to the Division of Quality Assurance, Office of Caregiver Quality, within five working days of the initial report and the date the entity knew or should have known about the misconduct. For one resident, the facility completed a thorough internal investigation of an incident but did not submit the required misconduct incident report to DQA within five business days of discovery. The resident involved had dementia with severe cognitive impairment (BIMS score 5/15), a history of falls, unilateral post-traumatic left hip osteoarthritis, anxiety, and documented pain related to osteoarthritis and multiple fractures. The resident was dependent on staff for transfers, toileting, and bed mobility, used a wheelchair, and required a mechanical lift for transfers. On 10/26/25, the resident experienced an incident during a Hoyer lift transfer when lifting their arms in the sling caused them to slide and be lowered to the floor; a cradle sling was later added as an intervention. Following the incident, the resident reported leg pain and was observed yelling out in pain, leading to a provider notification, portable x-ray, and subsequent identification of a tibial plateau fracture and possible femoral neck fracture. During a surveyor interview, the Nursing Home Administrator acknowledged that the incident had not been reported to DQA and stated it was not reported because they believed there was no immediate impact and that pain did not occur until hours later, despite recognizing that symptoms can develop later and that the presence of great bodily harm/fracture should have triggered reporting and submission of the final report within five business days.
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