Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an injury of unknown origin was promptly reported to management and the State Survey Agency as required. A resident with impaired cognition, hemiplegia, and dependence on staff for transfers and mobility was found to have redness and swelling on the right upper extremity. An x-ray revealed a significantly displaced acute proximal right humeral neck fracture. Staff were unaware of any falls or incidents that could have caused the injury, and the resident was only able to roll to the right and use the grab bar with the left hand for assistance. Despite the discovery of the injury, the nursing supervisor on duty did not notify the DON or Administrator about the incident. The DON was not made aware of the fracture until two days later, and the incident was not reported to the Ohio Department of Health until several hours after the DON was informed. Facility policy required immediate notification of the Administrator or designee and reporting to the State Survey Agency within two hours of identifying an injury of unknown origin, which was not followed in this case.