Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident who was reviewed for accidents. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and metabolic encephalopathy, was found to have acute, minimally displaced fractures of the right 10th and 11th ribs. Staff interviews and record reviews revealed that the resident had a documented fall on one date, with no injury or pain noted at that time or in the days following. Several staff members, including LPNs and CNAs, confirmed that the resident did not complain of pain or show signs of injury until a week later, when he began to guard his right side and express pain during movement. Upon discovery of the rib fractures, the Director of Nursing attributed the injuries to the earlier fall, despite the absence of pain or symptoms in the intervening period. The nurse practitioner and physician both expressed doubt that the fractures could have resulted from the earlier fall, given the delayed onset of pain and the typical presentation of rib fractures. The facility did not file a separate report for the injury of unknown origin, and the incident log did not list any other accidents or injuries for the resident between the fall and the discovery of the fractures. The facility's Abuse and Prevention Program requires that injuries of unknown source be reported to the Department of Public Health, especially when the source is not observed or cannot be explained and the injury is suspicious due to its extent. Despite this policy, the facility was unable to provide a report regarding the injury of unknown origin, and the only report submitted referenced the earlier fall, which staff and medical review could not conclusively link to the rib fractures.