Failure to Timely Report Resident Injury to State Agency
Penalty
Summary
The facility failed to report an unusual occurrence to the Department within 24 hours as required by its own policy and procedure. Specifically, the facility did not notify the Department when it became aware that a resident had sustained a further injury and dislocation of the right hip. The incident was identified on 1/9/2025, when an x-ray conducted at the facility confirmed the right hip dislocation. The resident, who had a history of right upper thigh fracture, recent right hip joint replacement, encephalopathy, difficulty walking, and muscle weakness, was noted to have moderate cognitive impairment and required substantial to maximal assistance with activities of daily living and mobility. The nursing progress notes and SBAR form indicated that the resident was transferred to a general acute care hospital for further evaluation after complaining of pain and discomfort. During an interview, the facility administrator acknowledged that the injury was not reported to the state agency as required. Review of the facility's policies confirmed that such unusual occurrences and injuries of unknown origin must be reported to appropriate agencies within 24 hours, but this protocol was not followed in this case.