Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
Facility staff failed to report an incident of injury of unknown origin to the State Agency within the required 24-hour timeframe for one resident. The resident, who had a history of repeated falls, difficulty walking, and seizures, was found to have severe cognitive impairment and required substantial assistance with activities of daily living. On the morning of the incident, the resident complained of right hip pain and was unable to get out of bed. Assessment revealed swelling and warmth in the right hip, and pain medication was administered without relief. An X-ray was ordered, which later confirmed an acute comminuted displaced intertrochanteric fracture of the right femur with associated soft tissue swelling. The resident was subsequently transferred to the hospital for further evaluation and admission. Despite being aware of the injury on the day it was discovered, facility staff did not submit the required Facility Reported Incident (FRI) to the State Agency until three days later. The Director of Nursing acknowledged the delay, attributing it to IT issues that prevented timely submission of the report. The failure to report the injury of unknown origin within 24 hours constituted a deficiency as identified by the surveyors.