Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who experienced an unwitnessed fall resulting in a hip fracture. Multiple staff interviews confirmed that the fall was not observed, and the resident was found on the floor by staff, complaining of pain. The resident, who had severe cognitive impairment and was dependent on staff for activities of daily living, was later sent to the hospital where imaging confirmed a right femur fracture. Documentation showed that the incident was unwitnessed, and the cause of the fall was unknown. The resident's family and physician were notified, but there was no evidence that the injury of unknown origin was reported to the appropriate authorities as required by facility policy. Review of the facility's policy indicated that all alleged violations, including injuries of unknown origin, should be reported to other agencies or law enforcement authorities. The Director of Nursing acknowledged that a five-day adverse event report should have been completed and that the incident should have been reported. The failure to report the injury of unknown origin constituted a deficiency in the facility's obligation to timely notify proper authorities of suspected abuse, neglect, or injury of unknown origin.