Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an injury of unknown origin, specifically a right arm fracture, to the State Survey Agency (SSA) and the Long-Term Care (LTC) Ombudsman for one resident. The resident, who had a cognitive communication deficit and muscle weakness, was observed with a contracted right hand in a sling and had been transferred to the hospital for further evaluation and treatment of the fracture. Nursing and progress notes did not document how the injury occurred, and there was no evidence of an investigation into the cause of the fracture. Interviews with the Assistant Director of Nursing (ADON) and the Social Worker (SW) confirmed that only a transfer notice was sent to the Ombudsman, and there was no documented notification to the SSA or the Ombudsman regarding the fracture of unknown origin. Both staff members acknowledged that the injury should have been reported and investigated according to facility policy, which identifies injuries of unknown source as requiring immediate investigation and reporting to appropriate authorities.