Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who was found to have a right hip fracture. The resident, who had a history of orthopedic aftercare, epilepsy, and bipolar disorder, was noted to have moderate cognitive impairment but no prior functional limitations in range of motion. On the morning in question, the resident complained of right hip pain radiating to the knee and was unable to perform activities of daily living without assistance, which was a change from his baseline. The certified nursing assistant (CNA) observed that the resident could not move his right leg and required two people to assist with care, prompting the CNA to notify the charge nurse (LVN). The LVN assessed the resident, noted the new pain and decreased range of motion, but did not observe any bruising or swelling. The LVN administered Tylenol and informed the resident's physician, who ordered additional pain medication but did not order diagnostic imaging. The LVN did not report the change in condition or the new symptoms to the director of nursing (DON), as required by facility protocol. The resident was subsequently transferred to a general acute care hospital for an unrelated issue, where a right hip fracture was discovered several days later. Upon the resident's return to the facility, the DON became aware of the hip fracture and recognized it as an injury of unknown origin. The DON confirmed that the incident was not reported to the state agency as required by both facility policy and regulation, and no investigation was conducted into the cause of the injury. Facility policies reviewed indicated that all injuries of unknown origin must be reported immediately and thoroughly investigated, but these steps were not followed in this case.