Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who was nonverbal and unable to advocate for himself. The resident, who had Lewy Body dementia and multiple medical diagnoses, was found by CNAs to have deep purple discoloration, swelling, and pain in his left leg. Upon assessment by a nurse, the leg was noted to be in an abnormal position, very firm to the touch, and the resident exhibited facial grimacing when range of motion was attempted. Emergency medical services were called, and the resident was transported to the emergency department, where a comminuted and markedly displaced fracture of the left femur was diagnosed. There was no reported fall, and staff were unable to explain how the injury occurred. The Director of Nursing (DON) did not report the injury immediately to the appropriate authorities, stating that the facility had not completed its investigation and was unsure if the injury was of known or unknown origin. The investigation was not started until two days after the injury was discovered, and the DON was unaware of the requirement to report injuries of unknown origin within two hours if serious bodily injury is involved, or within 24 hours if not. Facility policy required immediate reporting of suspected abuse or injury of unknown source, but this was not followed in this case.
Plan Of Correction
POC accepted with Spencer Hadley, admin 6/3/25 at 3:40pm. BIC date 5/15/25. CM, HFES 35362 Preparation and/or execution of this response and Plan of Correction (POC) do not constitute an admission or agreement by the provider of truth or accuracy of alleged facts or conclusions set forth in this Statement of Deficiencies. This POC is prepared and/or executed solely for provisions of Federal and State required regulations. This POC is not an admission of noncompliance with cited regulation(s). F 609 How corrective action(s) will be accomplished: All Residents may potentially be affected by this deficiency. A facility wide audit was conducted by the Assistant Director of Nursing (ADON) on 5/15/25 to review with facility Primary Care Physician (PCP) all residents. Nine (9) residents were identified as high risk related to diseases and co-morbidities. Care plans and diagnosis were updated on 5/15/25. PCP reviewed and ordered supplements if not contraindicated. In addition, a facility wide staff interview was conducted on 5/5/25 to determine if there are any residents who have visible injuries of unknown origin that need to be reported as an unusual occurrence. The results of the interviews did not determine any injury of unknown origin, which will require investigation. How will facility identify other residents having the potential to be affected: Director of Staff Development (DSD) proactively gave an in-service to staff on skin discolorations reporting, root cause analysis collaboration with team including nurse and peers on 5/6/25. DSD and DON collaborated in providing in-service to staff on Unusual Occurrence Policy and Procedures including time frame and reporting to appropriate agencies on 5/14/25. Administrator/Designee is the ultimate person responsible for reporting injuries of unknown origin to the Department of Health and other agencies. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not reoccur: Director of Staff Development (DSD) proactively gave an in-service to staff on skin discolorations reporting, root cause analysis collaboration with team including nurse and peers on 5/6/25. DSD and DON collaborated in providing in-service to staff on Unusual Occurrence Policy and Procedures including time frame and reporting to appropriate agencies on 5/14/25.