Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who was severely cognitively impaired, dependent on staff for all activities of daily living, and had a history of falls and muscle weakness. During morning care, staff observed a knot on the resident's right thigh, and the resident indicated pain. An x-ray was requested, which later revealed a comminuted and displaced fracture of the femoral diaphysis. The resident was subsequently sent to the hospital for further evaluation and treatment. The facility's policy required immediate reporting of suspected abuse, neglect, or injuries of unknown origin to the state agency and other authorities, especially when serious bodily injury was involved. Despite conducting an internal investigation, staff interviews, resident interviews, and skin audits, the facility did not report the injury of unknown origin to the state agency as required by their policy. The Director of Nursing confirmed that an investigation was initiated because the cause of the injury was unknown, but the required external reporting was not completed. The deficiency centers on the facility's failure to notify the appropriate authorities about the injury of unknown origin in accordance with regulatory requirements.