Failure to Timely Report Fracture of Unknown Origin
Penalty
Summary
The facility failed to report a fracture of unknown origin for a resident to the California Department of Public Health (CDPH), law enforcement, or the Ombudsman as required. The resident, who had diagnoses including Alzheimer's disease, schizophrenia, and Parkinson's disease, was severely cognitively impaired and dependent on staff for daily activities. The resident was found to have swelling and discoloration of the left hand, and subsequent x-ray results confirmed a non-displaced fracture of the fifth finger. Despite the absence of documentation explaining how the injury occurred, the results were not reported to the required authorities within the mandated two-hour timeframe. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) who received the x-ray results did not notify the appropriate agencies immediately, and the Director of Nursing (DON) only became aware of the incident several hours later. Facility policies and job descriptions reviewed during the investigation clearly stated the requirement to report suspected abuse, neglect, or injuries of unknown origin immediately, defined as within two hours. The failure to report the incident in a timely manner delayed the initiation of an investigation and did not comply with both facility policy and regulatory requirements.