Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made. Specifically, staff observed a resident with discoloration to the buttocks area, which was later confirmed as an acute femur fracture. Despite multiple staff members, including the ADON, DON, and CNA, recognizing the injury as one of unknown origin and acknowledging the requirement to report such incidents to the State Survey Agency (SSA), the injury was not reported as required. The resident involved had significant medical conditions, including bilateral primary osteoarthritis of the hip, age-related osteoporosis, schizoaffective disorder, vascular dementia, muscle weakness, lack of coordination, and severe cognitive impairment. The resident was at risk for falls and complications related to his diagnoses. Staff first noticed the discoloration and pain during routine care and subsequently ordered a stat x-ray, which revealed a right proximal femoral fracture. The resident was then transferred to the hospital for further evaluation and management. Throughout the process, staff interviews confirmed that the source of the injury was unknown and met the criteria for an injury of unknown origin. Despite facility policy and regulatory requirements mandating immediate reporting of such injuries, the DON, ADON, and other staff did not notify the SSA within the required timeframe. Interviews revealed that staff were aware of the importance of reporting injuries of unknown origin but failed to do so. The facility's in-service records also showed no recent training related to reporting injuries of unknown origin. The administrator stated she was not informed of the injury and only learned of it during the surveyor's interview.