Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state agency in a timely manner for a resident with severe cognitive impairment, legal blindness, and chronic pain syndrome. The resident, who was dependent on staff for all activities of daily living, was found to have a swollen, warm, and painful right knee during incontinence care. Nursing staff notified the provider, obtained orders for a STAT X-ray, and administered pain medication. The X-ray revealed acute nondisplaced oblique fractures of the right knee, but the results were not accessed or reported to the provider until two days later by the Assistant Director of Nursing. Despite the extent of the injury and the lack of a witnessed event or explanation from the resident, the facility did not file a self-reported incident for injury of unknown origin, as the provider deemed the injury idiopathic. Facility policy defined injuries of unknown origin as those not observed, not explained by the resident, and suspicious due to their extent, requiring timely reporting to state officials. The failure to report this incident was identified during a complaint investigation.