Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency as required by its Abuse, Neglect, and Exploitation policy. A resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease and osteoporosis with a history of pathological fractures, was found to have an additional fracture in the right humerus above a previously repaired site. The new fracture was discovered after the resident continued to experience significant pain despite receiving scheduled and as-needed pain medication. There was no documented fall or other incident to explain the new injury. The facility's policy mandates reporting all physical injuries of unknown source to the Administrator, State Agency, and other required agencies within specified timeframes. Despite this, the injury was not reported to the State Agency. The deficiency was identified during a surveyor's review of the resident's medical record and confirmed through staff interviews, including with the Nursing Home Administrator, who acknowledged the reporting requirement for injuries of unknown origin.