Failure to Report Fracture of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report a femur fracture of unknown origin for a resident to the California Department of Public Health (CDPH), resulting in a delay of investigation by the state agency. The resident, who had diagnoses including osteoarthritis of the hip, end stage renal disease, and was on dialysis, was found to have a right femur fracture after complaining of increased pain in her lower back, hips, and right leg. The x-ray confirmed the fracture, and both the family and physician were notified. The resident was cognitively intact and denied any fall, rough handling, or abuse, stating she did not know how the fracture occurred. Nursing staff, upon receiving the x-ray results, questioned the resident about possible causes, all of which she denied. The Director of Nursing and the Administrator were informed of the situation. The Administrator interviewed the resident, who again denied any incident or abuse, and the Administrator relied on the physician's assessment that the fracture was pathological due to the resident's long-term dialysis and underlying medical conditions. Based on this information, the Administrator determined that the incident did not meet the criteria for reporting as an unusual occurrence or injury of unknown origin. A review of the facility's policy indicated that all unusual occurrences are to be reported to the appropriate state agency within 24 hours. Despite this, the incident was not reported to CDPH, as the facility leadership believed the cause of the fracture was known and not suspicious. This decision was made even though the origin of the fracture was not clearly identified by the resident or staff, and the event was not reported as required by policy.