Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an injury of unknown origin for a resident who was admitted with multiple complex medical conditions, including an abscess of the right hip, MRSA infection, and Alzheimer's Disease. The resident was dependent on staff for all activities of daily living and was always incontinent. During the resident's stay, there was a documented change in condition, including a high fever, which led to the resident being sent to the hospital. Hospital staff later informed facility staff that the resident had multiple new fractures and a dislocated right hip, with no reported falls or witnessed injuries during the resident's stay. Despite being notified by the hospital of the fractures and dislocation, the facility did not report the injury as an injury of unknown origin to the state agency. The DON initiated an internal investigation, including staff interviews and skin sweeps of all residents, but discontinued the reporting process after the facility physician suggested the injuries could be attributed to infection rather than trauma. The facility's own policy defined an injury of unknown source as one not observed or explained, and suspicious due to its extent or location, which applied to this case. Interviews with facility staff, including the DON, RN, and Administrator, confirmed that injuries of unknown origin are required to be reported within two hours according to both facility policy and state regulations. However, the injury was not reported as required, and not all relevant staff were interviewed during the initial investigation. The deficiency was identified during a complaint investigation and was based on interviews, record reviews, and facility policy review.