Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its Incident Reporting Policy by not reporting a major injury to the Illinois Department of Public Health (IDPH) within the required 24-hour timeframe. A female resident with multiple diagnoses, including congestive heart failure, stage 3 sacral pressure ulcer, chronic kidney disease, seizures, lymphedema, and pulmonary hypertension, and a BIMS score indicating moderate cognitive impairment, sustained an acute right intertrochanteric femoral neck fracture. The injury occurred when a CNA, while providing peri-care in bed, inadvertently overturned the resident's right leg, resulting in the resident partially rolling out of bed. The resident complained of right hip pain following the incident, and an x-ray ordered by the attending physician confirmed the fracture. Despite the x-ray result being available on the evening of 5/9/25, the Director of Nursing (DON) was not made aware of the fracture until 5/13/25. The facility reported the incident to IDPH only after the DON became aware of the injury, exceeding the 24-hour reporting requirement. The facility's policy mandates that any serious injury, such as a fracture, must be reported to the state agency within 24 hours of discovery, but this protocol was not followed in this case.