Failure to Timely Report Unexplained Fracture to State Agency
Penalty
Summary
The facility failed to follow its abuse prevention and unusual occurrence reporting policies when it did not report an acute, new distal femur fracture of unknown cause for a resident to the State Survey Agency (CDPH) within 24 hours of becoming aware of the incident. The resident, who had diagnoses including age-related osteoporosis, dementia, and right knee contracture, was dependent on assistance for activities of daily living and lacked capacity to make decisions. The fracture was identified via X-ray, and the results were reported to the facility on 5/4/2025. However, the facility did not notify CDPH of the unusual occurrence until 5/7/2025, exceeding the required 24-hour reporting timeframe. Interviews with facility staff, including the RN Supervisor and DON, confirmed that the delay in reporting was not in accordance with facility policy, which requires reporting of such incidents within 24 hours. Review of the facility's policies further supported that all unusual occurrences and injuries of unknown origin must be reported promptly to appropriate authorities. The failure to report the incident in a timely manner was acknowledged by staff and documented in the facility's records.