Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required two-hour timeframe to the regulatory agency, the Office of Health Care Quality (OHCQ). Specifically, a resident with a history of dementia, failure to thrive, and multiple contractures was found to have a displaced fracture of the right hip. The resident, who was dependent on staff for all mobility, complained of right foot pain and was observed with swelling. The physician was notified, and orders were given for leg elevation, followed by an x-ray and doppler study. The x-ray, performed the following day, revealed a displaced fracture. Despite the discovery of the injury, the facility did not submit the initial report to OHCQ until two days after the x-ray confirmed the fracture. Review of the facility's investigation confirmed the delay in reporting, and the Director of Nursing acknowledged that staff failed to notify administration in a timely manner. This deficiency was identified during a complaint survey and was evident for one of four residents reviewed for facility-reported incidents.