F0609

D

Failure to Timely Report Serious Injury of Unknown Origin and Investigation Results

Haverstraw, New York Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report an alleged violation and injury of unknown origin involving Resident #4 to the New York State Department of Health (NYSDOH) within required timeframes. Resident #4 had diagnoses including anemia, dementia, and hypothyroidism, with an Annual MDS dated 10/24/2025 documenting severely impaired cognition, a need for supervision with bed mobility, and substantial to maximal assistance with transfers, toileting, and showers. On 01/21/2026 at 11:00 AM, while being turned and positioned, Resident #4 was observed guarding the right knee, complaining of pain, and exhibiting swelling of the right knee. The charge nurse was called, and a STAT right knee x-ray was ordered and completed.

On 01/21/2026 at 07:55 PM, the radiology report documented an acute nondisplaced fracture of the right tibial plateau, constituting a serious bodily injury. At 08:37 PM, an SBAR note documented the x-ray result and a provider recommendation to transfer the resident to the hospital for further evaluation. At 10:00 PM, the physician was notified of the x-ray findings, and the nursing progress note at 10:03 PM recorded that the Director of Nursing was made aware and that the resident was transferred via EMS to the hospital. The facility’s hospital transfer form documented that the transfer occurred at 10:11 PM on 01/21/2026. The hospital after-visit summary received by the facility at 02:18 AM on 01/22/2026 documented four views of the right knee and a questionable fracture of the lateral tibial plateau.

Despite the fracture being identified on 01/21/2026, the facility did not report the injury of unknown origin to NYSDOH until 01/22/2026 at 1:20 PM, exceeding the regulatory requirement to report serious bodily injury not later than 2 hours after identification. The Nursing Home Investigation Form submitted to NYSDOH documented the date of incident as 01/22/2026 and indicated that the resident was identified with an injury, although the injury had been identified the previous day. The facility was required to submit the investigative report within 5 working days of identifying the injury, which would have been 01/28/2026, but the investigative report (Submission #22298) was not submitted until 02/09/2026, 13 days after the injury was identified. During an interview on 02/12/2026, the Director of Nursing stated that the facility documented the date of incident as 01/22/2026, initiated the incident report and investigation upon the resident’s return, and waited for confirmation of receipt from NYSDOH before sending the investigative report, contributing to the delay beyond the required 5-working-day timeframe.