Failure to Report Unwitnessed Fall With Potential Injury to State Agency
Penalty
Summary
The facility failed to report an alleged incident involving an unwitnessed fall with potential injury to the State Agency as required by its Abuse Prohibition policy. The policy, revised on 11/14/25, prohibits neglect and requires immediate reporting, investigation, documentation, and follow-up of alleged injuries, including injuries of unknown source. It directs the facility to initiate an investigation within 24 hours of receiving information about an injury or suspected neglect, document interviews and findings, notify the physician and resident representative, and submit findings of completed investigations within five days to the State Agency. Record review showed that a resident with dementia, muscle weakness, and major depression experienced an unwitnessed fall in her room, after which staff documented a swollen left hand. A Telehealth provider was contacted and ordered an x-ray of the hand, which later showed no fracture or dislocation. The DON stated that an unwitnessed fall with hand swelling and an x-ray to rule out injury met the criteria for reporting to the State Agency due to the potential for injury. The Administrator confirmed awareness of the fall and acknowledged that the incident should have been reported to the State Agency but was not, resulting in the failure to follow the facility’s abuse/neglect reporting requirements.
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