Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident who was reviewed for abuse and neglect. According to facility policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source—must be reported immediately, but not later than 2 hours if abuse or serious bodily injury is involved, or within 24 hours otherwise. The resident in question had multiple diagnoses including osteoarthritis, anxiety, dementia, and Alzheimer's disease, and was dependent on staff for transfers and mobility. The resident was found to have multiple bruises on the right upper arm and shoulder after complaining of pain during repositioning. The incident was documented as non-witnessed, with the cause listed as unknown at the time. Subsequent assessment revealed limited range of motion and pain, leading to a STAT X-ray and transfer to a hospital, where a displaced fracture of the right humerus was diagnosed. Interviews with facility leadership confirmed that the injury was not reported as an injury of unknown origin, despite the lack of a clear cause and the requirements of facility policy. The administrator stated that the injury was not reported because it was not believed to be from willful intent to harm, and could not provide documentation of an investigation or root cause analysis. The medical director confirmed that all injuries of unknown origin should be reported, and the administrator acknowledged that the injury was not reported as required.