Failure to Report Fall With Injury to State Survey Agency
Penalty
Summary
The facility failed to submit a Facility Initiated Report and a five‑day follow‑up report to the State Survey Agency after a resident sustained a fall with injury. Progress notes dated 02/28/26 at 5:23 p.m. documented that the resident experienced a fall that morning resulting in a 7.0 cm x 2.0 cm laceration to the right side of the forehead and was transported to a local hospital. During an interview, the resident’s daughter reported that she first learned of the incident when the hospital called her to obtain permission to treat her mother for the forehead laceration caused by a fall at the facility. In a separate interview, the Administrator acknowledged awareness of the incident and stated that any fall with injury should be reported to the state agency, confirming that this fall had not been reported as required. This deficient practice is likely to result in the State Survey Agency not being aware of facility incidents and being unable to assure residents’ safety.
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