Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident within the required timeframe to the State Survey Agency (SSA), as mandated by facility policy. The resident, who had diagnoses including Alzheimer's disease, dementia, cerebral ischemia, and a history of falls, was observed by a Restorative Aide to be favoring his left shoulder. The aide noticed a knot below the resident's shoulder and reported it to the Unit Manager immediately. Subsequent medical evaluation, including an x-ray and orthopedic consultation, led to a diagnosis of a dislocated left shoulder, and the resident was sent to the emergency department for treatment. Staff interviews and record reviews indicated that no recent falls or incidents were reported, and the origin of the injury could not be determined. Despite the facility's policy requiring immediate reporting of such incidents, the injury was not reported to the SSA within the required timeframe. Documentation showed that the injury was first observed and reported internally, but the formal Facility Incident Report was not submitted to the SSA until later. The delay in external reporting constituted a failure to comply with abuse prevention and reporting protocols, as outlined in the facility's own policy and federal regulations.