Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state agency within the required two-hour timeframe for one resident. The resident, who had severe cognitive impairment and was dependent on staff for all mobility and care needs, was found with a shortened and rotated right leg. Nursing staff notified the resident's Power of Attorney and a Nurse Practitioner, who assessed the resident and ordered x-rays. The x-ray revealed a new comminuted fracture of the distal femur, and the resident was subsequently hospitalized for surgical repair. There was no evidence or report of a fall or trauma, and the resident was unable to explain the cause of the injury. Despite the facility's policy requiring injuries of unknown source to be reported if the cause is unobserved or unexplained, the injury was not reported to the Illinois Department of Public Health. The Administrator stated that the injury was not reported because the Nurse Practitioner did not suspect abuse due to the absence of bruising and because the physician later determined the fracture was pathological. The timeline from the initial observation to the physician's assessment and diagnosis was immediate, but the required state notification was not made.