F0609

D

Failure to Report Resident Fall With Pelvic Fracture to State Agency

Blair, Nebraska Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The facility failed to timely report a significant injury related to a fall to the state agency as required by its abuse, neglect, and exploitation policy and state regulations. The facility’s written policy, dated 09-23-2022, required procedures for identifying possible abuse, neglect, and exploitation, including physical injury of unknown source, and mandated reporting of all alleged violations to the administrator, state agency, adult protective services, and other required agencies within specified time frames. These time frames were defined as immediately, but no later than 2 hours when events involve abuse or result in serious bodily injury, and no later than 24 hours when events do not involve abuse and do not result in serious bodily injury.

Record review showed that one resident had significant functional and cognitive impairments, including being rarely able to make self-understood, always incontinent of bowel and bladder, requiring extensive assistance with toilet transfers, and total assistance with lower body dressing, personal hygiene, bed mobility, and transfers. Progress notes documented that this resident fell on 12-19-2025 while being transferred from the toilet to a wheelchair, complained of left knee pain, and was sent to the emergency room. The following day, the resident complained of left hip pain, with staff noting the left leg was rotated inward and shorter than the right, leading to hospital transfer and admission for a possible pelvic fracture. Hospital records and the after-visit summary confirmed a closed fracture of the left inferior pubic ramus (pelvic fracture). In interviews, the DON and the administrator confirmed that this fall with pelvic fracture was not reported to the state agency because the facility believed it was not a new injury.