Incomplete Investigative Reports Submitted After Falls With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to submit comprehensive investigative reports to the State Agency for two residents who experienced falls with major injuries. Facility policy on Abuse, Neglect, Exploitation and Misappropriation Prevention, revised April 2021, required the facility to investigate and report any allegations within timeframes required by federal requirements. For one resident admitted on an unspecified date and discharged on 2/22/2026, progress notes dated 2/20/2026 documented a fall on 2/19/2026 that resulted in a laceration to the left side of the head, a left wrist fracture, and a left femur fracture. The Investigation Report dated 2/24/2026 described the incident and stated that no permanent measures were put into place to prevent recurrence, noting that the resident was admitted to the hospital and that the family elected not to have surgery due to a heart condition. The outcome section attributed the fall to the resident being non-compliant with transfers, attempting to self-transfer, and not calling for assistance. The Director of Nursing confirmed that this Investigation Report was the document submitted to the State Agency and that it did not contain information regarding interventions implemented after the resident returned from the hospital, despite such information existing. For another resident admitted on an unspecified date and discharged on 10/17/2025, progress notes dated 10/3/2025 documented an unwitnessed fall in a sitting area that resulted in a laceration on the nose requiring sutures and a subsequent diagnosis of a fractured nose. A facility document labeled “October 2025 Reportable” described the incident timeline and indicated that a fall committee would meet to discuss current interventions and decide on modifications, and that staff would increase checks on rounds while the resident was in bed and that the resident was not to be left in a wheelchair without supervision. The DON confirmed that the investigative report submitted to the State Agency for this fall did not contain a thorough investigation into the resident’s fall.
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