Failure to Timely Identify and Investigate Major Injury of Unknown Origin
Penalty
Summary
The facility failed to identify and investigate a major injury of unknown origin in a timely manner for a cognitively impaired, non-verbal, and non-ambulatory resident. The resident was found to have a femur fracture that was already partially healed by the time it was discovered, indicating the injury had occurred at least two to three weeks prior. Staff had noticed the resident's leg appeared awkward for some time but did not report or address the concern, assuming it was normal for the resident. When the resident eventually cried out during care, nursing staff were called to assess, and the resident was sent to the emergency room, where the fracture was confirmed. Multiple staff interviews revealed that there was uncertainty about the cause of the fracture, with some staff doubting the explanation that the injury was caused by the resident's foot being caught under a heater. The treating surgeon and other medical professionals noted the absence of bruising and the advanced healing of the fracture, making it difficult to repair. The injury was not recognized as acute, and the facility did not conduct a thorough investigation into the origin of the injury or consider it as a potential case of abuse or neglect, despite the resident's vulnerability and inability to communicate. The facility's own policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or distress. In this case, the lack of timely identification, reporting, and investigation of the injury, as well as the failure to interview all relevant staff and review medical reports, constituted neglect. The delay in recognizing and addressing the injury increased the risk of further harm and negative outcomes for the resident.