Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to immediately report an injury of unknown origin, later determined to be a fracture, to the state survey agency within the required two-hour timeframe. A resident with severe cognitive impairment, hemiplegia, hemiparesis, and total dependence on staff was observed by a CNA during morning care to have a swollen, warm, and tender right arm with limited range of motion and facial grimacing. The CNA promptly notified the nurse, and subsequent documentation by nursing staff confirmed the findings. An x-ray later revealed a fracture of the right humeral shaft. Despite the facility's policy requiring immediate reporting of injuries of unknown origin, especially those resulting in serious bodily injury, the incident was not reported to the state agency until the following day. Interviews with facility staff, including the DON, RN Unit Manager, and Administrator, revealed a lack of clarity and timely action regarding the reporting process. The DON and RN Unit Manager acknowledged that the injury should have been reported within two hours, and the Medical Director confirmed the fracture was of unknown origin and not pathological. The delay in reporting was attributed to uncertainty about the cause of the injury and miscommunication among staff regarding responsibility for notification. The incident was ultimately reported more than 24 hours after initial discovery, in violation of regulatory requirements.