Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report and submit an investigation for an injury of unknown origin to the State Agency and adult protective services within the required time frames for one resident. According to the facility's policy, all alleged violations, including injuries of unknown origin, must be reported to the administrator, state agency, and adult protective services immediately, but not later than two hours if the event involves abuse or results in serious bodily injury, or within 24 hours if it does not. A resident with severe cognitive impairment, hemiplegia, diabetes, dementia, and a history of stroke was found to have a healing humerus fracture of unknown origin after returning from a primary health care provider visit. The resident's care plan documented multiple prior falls without injury, and the medical record did not identify a probable or possible source for the fracture. Interviews with facility staff confirmed that the provider notified the facility of the fracture, and an internal investigation suggested the injury may have occurred prior to admission, based on information from the resident's responsible party. However, the Assistant Director of Nursing and the Regional Director of Operations both confirmed that the state agency and adult protective services were not notified, and no written report or investigation was submitted to the state agency as required by facility policy and regulatory requirements.