Failure to Timely Report Alleged Neglect and Injury of Unknown Source
Penalty
Summary
The facility failed to report an allegation of neglect involving a female resident with severe cognitive impairment, multiple comorbidities, and total dependence for activities of daily living. The resident complained of left knee pain, which was assessed by an LVN, and an x-ray was ordered after notifying the physician. The x-ray revealed a chronic fracture of the distal femur, and the resident was subsequently transferred to the hospital, where an acute oblique distal left femoral diaphyseal fracture was diagnosed, requiring surgical intervention. Despite these findings, the incident was not reported to the State Agency within the required timeframes. Interviews with the DON and Administrator revealed that the incident was not reported because the fracture was believed to be chronic and attributed to the resident's age and osteopenia, and thus not considered suspicious or related to abuse or neglect. The facility's abuse policy and relevant provider letters require immediate reporting of incidents involving neglect, exploitation, or mistreatment, including injuries of unknown source, but the facility did not follow these protocols in this case.