Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically in relation to an injury of unknown origin sustained by a resident. The resident, who had chronic pain, vascular dementia, and was dependent for all activities of daily living, was found to have a nondisplaced distal radius fracture after being transferred to the hospital. The hospital records indicated swelling, tenderness, and pain in the resident's left arm, with imaging confirming a concerning lucency in the distal radius. Despite these findings, the facility did not report the injury of unknown origin to the state agency as required by their abuse policy and federal regulations. The facility's internal investigation into the incident did not address the injury of unknown origin, even though the hospital records noting the fracture were present in the facility's incident folder. Interviews revealed that the administrator and medical director did not review or recognize the x-ray findings indicating a possible fracture. The administrator confirmed that such an injury should have been reported to the state agency but was unable to explain why this was not done. The family member of the resident also reported concerns about the injury, noting the resident's inability to self-inflict such harm due to being bedbound and dependent on staff for care. The facility's abuse policy required immediate reporting of any allegations or reasonable suspicions of abuse, neglect, or injuries of unknown source to the state agency and other authorities. However, the injury was not reported as required, and the investigation did not address the injury of unknown origin. This failure to report and investigate the injury in accordance with policy and regulatory requirements constituted the deficiency identified by surveyors.