Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident involving a resident who was found with facial bruising and a posterior nasal fracture of unknown origin. The resident, who had intact cognition and was able to communicate, was admitted with multiple medical conditions including acute respiratory failure, tracheostomy, and morbid obesity, and required mechanical ventilation. On the evening of the incident, the resident was observed with facial swelling and green discharge from the right eye, prompting a transfer to the hospital for further evaluation. The hospital later diagnosed the resident with a minimally displaced left posterior sinus wall fracture, but there was no documented trauma or incident preceding the injury, and the resident did not report any event that could have caused it. Despite the facility's policy requiring immediate reporting of injuries of unknown origin to the State Agency, the incident was not reported as required. The Director of Nursing confirmed that while an internal investigation was initiated by the Nursing Home Administrator, there was no evidence that the incident was reported to the State Agency. The facility's abuse policy specifically mandates reporting all injuries of unknown source that are suspicious in nature within 24 hours, but this protocol was not followed in this case.
Plan Of Correction
This plan of correction is submitted to meet state and federal requirements. Except with respect to statements finally determined to be indisputable, submission of this plan of correction is not an admission that the deficiency exists or that it is cited accurately. ELEMENT # 1 The resident identified (R702) has returned from the hospital and is receiving services per her plan of care. ELEMENT # 2 The Director of Nursing (DON) and/or their appropriate designee will assess each resident to ensure any unusual findings have been addressed and reported if necessary. ELEMENT # 3 The citation states: “the facility failed to report facial bruising and posterior nasal fracture of unknown origin for one (R702)...” The facility will ensure the following action: 1) The facility policy titled “Abuse and Neglect Prohibition Policy” will be reviewed and updated to ensure clarity; 2) Facility staff will receive re-education on the facility’s updated policy with an emphasis on identifying and timely reporting any injuries of unknown origin to the Administrator; 3) Any discovery of an injury of unknown origin will also be reported to the nurse on staff at the time of discovery who will then be responsible for informing the incoming nurse of the following shift to ensure proper attention is provided related to reporting and follow-up investigation and/or care if necessary; 4) Any injury of unknown origin will be reported to the Administrator and relayed to the DON upon knowledge; 5) The Administrator or the DON as their designated representative will timely report to any other required parties the discovery of the injury of unknown origin and the result of the investigation; and 6) In cases of verified violations of this facility policy, the Administrator will ensure timely and appropriate corrective action is taken. ELEMENT # 4 The DON and/or their appropriate designee(s) will randomly assess 25% of the residents for a period of three consecutive months to ensure any injuries of unknown origin have been identified, addressed, and reported appropriately. Random assessments for 25% of the residents will occur three times per week for the first month, twice per week for the second month, and once a week for the third month. Any instances of non-compliance with the facility policy will be reported to the Administrator, DON, and abuse coordinator for appropriate follow-up. The Administrator will report any outcome or concern related to the cited deficiency to QA for three months. The Administrator is responsible for sustained compliance.