F0609

D

Failure to Timely Report Unwitnessed Fall With Hip Fracture to State Agency

Fresno, California Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its written policy and procedure for timely reporting of an unusual occurrence when a resident sustained an unwitnessed fall with a serious injury. On the early morning of 3/4/26, a CNA was assisting the resident’s roommate behind a privacy curtain when the CNA felt something touch her back; upon turning, the CNA found the resident on the floor between the two beds. LVN 2 was called to the room at approximately 5:30 a.m., assessed the resident on the floor, and documented that the resident complained of lower back and left hip pain, had facial grimacing, and was unable to move her legs due to pain. LVN 2 kept the resident on the floor to avoid further movement, contacted the physician, and obtained an order to transfer the resident to the hospital via 911.

The Director of Business Development (DBD) stated that, as part of her responsibilities, she contacted the hospital on 3/4/26 and confirmed that the resident had been admitted with a hip fracture due to the fall and was scheduled for surgery the following day. She reported that she notified both the DON and the Administrator of the hip fracture on that same day and later entered this information as a late entry progress note dated 3/9/26 for the events of 3/4/26. The hospital’s emergency department to hospital admission documentation indicated that imaging on 3/4/26 showed an acute fracture of the femoral neck with impaction and angulation, and that the resident underwent a left hip hemiarthroplasty.

Despite the facility’s policy requiring that unusual occurrences affecting the welfare, safety, or health of residents be reported by telephone to appropriate agencies within 24 hours, the Administrator and DON did not report the fall with hip fracture to the California Department of Public Health (CDPH) until 3/18/26. The DON acknowledged that a hip fracture is a serious injury and stated that a report should be made to CDPH as soon as the facility knows a resident has an injury, and that they could have reported without having the hospital records. The Administrator confirmed he was responsible for reporting falls with severe injuries, acknowledged being notified on 3/4/26 that the resident had a hip fracture, and stated that the fall with fracture was reported to CDPH on 3/18/26. The facility’s incident report, completed on 3/18/26, documented the unwitnessed fall on 3/4/26, the resident’s complaints of pain and inability to move due to pain, the transfer to the hospital, and that hospital documentation was not received until 3/18/26.