Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an injury of unknown origin was reported to the appropriate agencies immediately, but not later than 2 hours after the injury was noted, as required by both federal and state regulations. The facility's own policy mandates immediate reporting of any incident or suspected incident of resident abuse, neglect, or injuries of unknown source to the Abuse Coordinator and appropriate state agencies. In this case, a resident with severe cognitive impairment and significant physical dependencies was found to have multiple bruises, abrasions, and ultimately, bilateral displaced femur fractures of unknown origin. Despite the presence of these injuries and escalating pain, there was no timely report made to the state agency as required. The resident, who was non-ambulatory and dependent on staff for all transfers and care, began exhibiting increased pain and spasms in her lower extremities. Over the course of several days, staff documented high pain scores, visible bruising, and excoriations, but did not initiate a report of suspected abuse or injury of unknown origin. Family members observed and documented multiple injuries and expressed concerns to staff, but these concerns were not escalated or reported as required. Medical providers and hospital staff later confirmed the presence of acute, displaced fractures and extensive bruising, with no clear explanation for the injuries. Interviews with facility staff, including the administrator and DON, revealed a lack of consensus or clarity regarding the cause of the injuries, with some attributing them to osteoporosis or immobility, despite medical opinions stating that an external force or trauma is required for such fractures. The facility's internal investigation was incomplete, lacking signed statements, a clear timeline, or thorough staff interviews. The administrator did not consider the injuries to be of unknown origin and therefore did not report them to the state agency, contrary to regulatory requirements. There was no evidence of staff education or corrective action in response to the incident at the time of the survey. The failure to report the injuries of unknown origin in a timely manner constituted a violation of both facility policy and federal/state regulations.