Failure to Report Fracture of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report a fracture of unknown origin to the State Agency (SA) for one resident, as required by both regulation and facility policy. The resident, who had a history of dementia and falls, experienced a fall during therapy, which was documented with no injury or pain at the time. Over a month later, the resident's family requested an x-ray due to complaints of pain, but the x-ray was negative for acute fracture. Subsequently, the resident was sent to the hospital for mental status changes, where a right hip fracture of unknown origin was discovered. There was no documentation of any additional falls after the initial incident in therapy. Interviews with staff revealed that the RN who ordered the x-ray did not inquire about the timing of any new fall, and the DON confirmed that an investigation was initiated but not reported to the SA. The NHA was unaware of the incident until the survey and acknowledged that the fracture should have been reported. The facility's abuse policy requires immediate reporting of injuries of unknown source to the SA, but this was not followed in this case.