Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown origin for a resident who was later diagnosed with a nondisplaced proximal fibular fracture. The incident began when the resident, who had diagnoses including vascular dementia, muscle wasting, osteoporosis, and weakness, was being assisted from the toilet to her wheelchair by two CNAs. During the transfer, the resident's knees gave out, and she requested to be seated on the floor. Both CNAs and the resident agreed to this, and a nurse was called to assess her. The nurse performed a head-to-toe assessment and found no abnormalities or pain reported by the resident at that time. The resident was transferred back to bed using a mechanical lift, and no incident report or change of condition was completed because the nurse did not consider it a fall. Several days later, the resident began to experience pain in her lower right leg, which she reported to the nurse practitioner (NP) during rounds. The NP ordered an x-ray, which revealed a nondisplaced proximal fibular fracture. The NP accepted the findings but ordered a second x-ray to confirm the injury, which also indicated a fracture. Despite receiving the first x-ray results, the administrator delayed reporting the injury to the state agency, waiting for the results of the second x-ray before submitting the report. The injury was ultimately reported more than 24 hours after the initial diagnosis, exceeding the required 2-hour reporting window for injuries of unknown origin. Interviews with staff confirmed that the incident was not reported promptly due to the initial lack of pain or visible injury and the belief that it was not a fall. The DON acknowledged that the nurse failed to complete an incident report or notify her of the event, and the administrator confirmed the delay in reporting was due to waiting for confirmation from a second x-ray. The facility's policy requires immediate reporting of such incidents, but this protocol was not followed in this case.