Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report, or report within 24 hours, an injury of unknown origin for a resident with severe cognitive impairment and no capacity to make decisions. The resident was found with swelling, redness, and warmth in the left elbow, and an X-ray confirmed a left shoulder dislocation. The resident was subsequently transferred to a general acute care hospital for further evaluation. Despite these findings, the incident was not reported to the California Department of Public Health (CDPH) as required. Interviews with the DON and Administrator revealed that the injury was not reported because they considered the shoulder dislocation to be a chronic issue based on the resident's previous medical history, rather than an acute event. The facility's policy required immediate reporting of injuries of unknown origin, but this was not followed. As a result, CDPH was unable to investigate the injury in a timely manner, and there was potential for facts related to the injury to be lost or forgotten.