Failure to Timely Report Unexplained Fracture as Possible Abuse
Penalty
Summary
The facility failed to report a resident's right thumb fracture to the California Department of Public Health (CDPH) within the required two-hour timeframe, as mandated by federal regulations. The resident, who had a history of tracheostomy, gastrostomy, ventilator dependence, and dementia, was found to have redness and swelling on the right thumb, which was later confirmed by x-ray to be an acute nondisplaced fracture. The resident was highly dependent, unable to communicate, and lacked decision-making capacity. The injury was not witnessed by staff, and there was no explanation provided by the resident due to their condition. Despite the facility's policy requiring immediate reporting of suspected abuse or unexplained injuries, the Administrator, who also served as the abuse coordinator, did not report the incident to CDPH, citing the absence of hospitalization or surgical intervention. The Registered Nurse involved recognized that the injury could be a result of abuse or mishandling, as it was unexplained and severe. The facility also failed to send the results of the abuse investigation to the State Survey Agency, contrary to their own policies and regulatory requirements.