Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency as required by its Abuse Prohibition Policy. The policy mandates that the Abuse Coordinator report injuries of unknown source with serious bodily injury within two hours of the allegation. In this case, a resident with significant cognitive impairment and dependent for transfers was found to have bilateral displaced femoral neck fractures, which were identified during a hospital evaluation for seizure-like activity. The investigation into the cause of the fractures was inconclusive, with possible causes including a pathological process, seizure activity, or a rough transfer by EMS, as reported by the resident's responsible party. Despite the inability to determine the cause of the fractures, the facility did not report the incident to the State Agency, believing the injuries to be pathological. The investigation file lacked documentation such as staff witness statements, records of conversations with the responsible party prior to the injury, and supporting evidence for the conclusion that the fractures were pathological. The administrator later acknowledged that the cause could not be determined and that the incident met the definition of an injury of unknown origin that should have been reported.