Failure to Timely Report Unwitnessed Fall With Hip Fracture to State Authorities
Penalty
Summary
The facility failed to ensure that an alleged violation involving an unwitnessed fall with serious bodily injury was reported to the New York State Department of Health (NYSDOH) within the required timeframe. Facility policy on Abuse, Mistreatment, Neglect, and Misappropriation of Resident's Property required that the Director of Nursing coordinate investigations of alleged violations and report all alleged violations and substantiated incidents to NYSDOH. Regulations required that alleged violations involving abuse or resulting in serious bodily injury be reported immediately, but not later than 2 hours after the allegation was made. Despite these requirements, there was no documented evidence that the resident’s unwitnessed fall and resulting major injury were reported to NYSDOH. The deficiency involved a resident with diagnoses including cerebral infarction, right hemiplegia, and dysarthria, who had severely impaired cognition and required supervision or touching assistance for bathing, dressing, toileting hygiene, transfers, and walking. On the date of the incident at approximately 8:30 PM, the resident was found sitting upright on the floor in their room with their back against the wall, limited range of motion, and complaints of pain in the right hip area, after having last been seen in bed at 8:10 PM. The resident, who was forgetful and confused at baseline and had a history of attempted unassisted transfers despite requiring extensive assistance of one person, was transferred to the hospital and diagnosed with a right intertrochanteric hip fracture, requiring surgical fixation. The DON and Administrator, both hired after the incident, acknowledged during interviews that this unwitnessed fall with hip fracture constituted a major injury that should have been reported to NYSDOH within two hours, but it was not reported.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.