Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an injury of unknown origin involving a resident to the State Survey Agency within the required two-hour timeframe after discovery. The incident involved a resident with severe cognitive impairment who was found to have swelling in the right shoulder, hand, and arm, which was first noticed by the resident's sister and subsequently assessed by nursing staff. The injury was not witnessed, and the resident was unable to provide an explanation due to cognitive limitations. The resident was transferred to the hospital, where an X-ray confirmed an anterior shoulder dislocation. Despite the facility's policy requiring prompt reporting of injuries of unknown origin, the Director of Nursing and the Administrator did not report the incident to the State Survey Agency, as they believed only fractures required reporting. The facility was unable to determine how or when the injury occurred, and the event was not reported as required by regulation. This deficiency was identified through record review and staff interviews, and it had the potential to affect all residents in the facility.