F0610

E

Failure to Investigate and Document Elevator-Related Resident Injury

Elmira, New York Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to investigate and document an alleged neglect incident in which a resident was injured by an elevator door. Facility policies required that all accidents and incidents be investigated by the department director, that serious accidents or unusual frequencies of accidents be investigated by the Safety Committee, and that an incident report be prepared when equipment was involved in an injury. The resident had diagnoses including polyneuropathy and osteoarthritis, was cognitively intact, and used a manual wheelchair for mobility. Progress notes documented that the resident bumped their left arm on the elevator doors and later reported left wrist and forearm pain after the elevator door closed on their arm, with observed bruising and slight swelling. An orthopedic evaluation found no acute bony abnormality and recommended conservative management.

Despite these documented injuries and the involvement of elevator equipment, the facility did not complete an incident report, initiate an investigation, or conduct a root cause analysis. The Director of Facilities reported no work order was received related to the elevator closing on the resident’s arm. The RN Manager stated that after the incident the focus was on caring for the resident and notifying administration, and confirmed that an incident report was not completed. The DON stated that an incident report and investigation report related to the elevator injury could not be located and were not completed. Facility documentation showed no evidence that an investigation was initiated, no root cause analysis was conducted, and no Safety Committee review occurred following the incident, contrary to facility policy and regulatory requirements.