Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Survey Agency as required by policy and regulation. A resident with severe cognitive impairment and multiple medical conditions, including atrial fibrillation, muscle wasting, and chronic kidney disease, was found with pain, redness, and swelling in the right lower extremity. Subsequent assessment and a stat x-ray revealed a fracture, and the resident was transferred to the emergency department per physician order. The facility initiated an internal investigation, which included review of witness statements, but no staff reported witnessing the injury or any change in the resident's condition prior to the complaint of pain. Despite the facility's policy requiring the reporting of all alleged violations involving mistreatment, neglect, or abuse—including injuries of unknown origin—to the Department of Health and other relevant agencies, there was no evidence that the injury was reported to the State Survey Agency. The Director of Nursing confirmed that the required report was not submitted within the mandated timeframe, resulting in noncompliance with state regulations regarding the timely reporting of suspected abuse, neglect, or injury of unknown origin.