Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the state survey agency for one resident who suffered a new fractured humeral shaft. The resident was admitted to the facility with a prior left humerus fracture and had not experienced any falls or trauma since admission, according to staff documentation and interviews. On a follow-up appointment, it was discovered that the resident had a new fracture requiring surgery, but staff believed it was related to the initial injury and did not recognize it as a new event. The LPN reported the finding to the DON and ADON, but the incident was not reported to the state agency as required by the facility's abuse prevention policy. Interviews with the DON, ADON, and Administrator revealed a lack of clarity regarding whether the fracture was new and whether it constituted an injury of unknown origin. The DON did not consider the fracture reportable due to insufficient information and the absence of witnessed incidents, while the Administrator was unaware it was a new fracture until the state agency's investigation. The facility's policy required immediate reporting of injuries of unknown source, but this was not followed in this case.