Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an injury of unknown origin for one resident, which was required by their abuse prohibition policy. The resident, who had severe cognitive impairment due to Alzheimer's and dementia, was found to have a left wrist fracture with no documented falls or witnessed incidents. Nursing notes indicated an acute radial fracture, and an X-ray confirmed a hairline fracture of the distal radius. Despite a full investigation into the cause of the fracture, the etiology could not be determined, and there were no witnesses to the injury. Staff interviews revealed that the LPN was notified of the resident's swollen wrist and reported the incident to the DON after learning of the fracture. The administrator, who served as the abuse coordinator, acknowledged that the incident should have been reported as an injury of unknown origin within the mandated timeframe but confirmed that no report was made to the state agency. The facility's failure to report the injury as required decreased their ability to protect the resident and ensure a safe environment during the investigation.