Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who experienced a significant change in condition, specifically right hip pain and decreased range of motion, which was later diagnosed as a right hip fracture. The resident, who had moderate cognitive impairment and no prior functional limitations in range of motion, was found by a CNA to be unable to move his right leg and required increased assistance with activities of daily living. The CNA notified the LVN, who assessed the resident but did not observe visible bruising or swelling and administered Tylenol for pain. The LVN did not escalate the change in condition to the Director of Nursing (DON) or recommend further assessment, such as an X-ray, and only informed the resident's physician, who ordered additional pain medication but no diagnostic imaging. The resident was subsequently transferred to a general acute care hospital for an unrelated incident, where a right hip fracture was discovered several days later, necessitating surgery. Upon the resident's readmission to the facility, the DON became aware of the hip fracture and, upon review, determined that the injury was of unknown origin, as neither staff nor the resident could explain how it occurred. The facility's policy required that injuries of unknown origin be reported to the state agency immediately, but this was not done because the DON was not informed of the initial change in condition or the injury at the time it occurred. Interviews with staff revealed that the LVN did not consider the resident's complaints and decreased mobility to be significant enough to warrant supervisor notification or further investigation. The DON confirmed that, according to facility policy, the injury should have been reported to the state agency as soon as it was discovered, but this did not happen due to a lack of communication and awareness among staff. The failure to report the injury of unknown origin constituted a deficiency in the facility's abuse, neglect, and exploitation reporting procedures.