Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse prevention policy regarding the timely reporting of an injury of unknown origin for one resident. The resident, who had significant cognitive impairment and was dependent on staff for all mobility and transfers, was transferred to the hospital after being found weak, pale, and difficult to arouse. Hospital records revealed that the resident had sustained a fracture of the right acetabulum and a compression fracture of the first lumbar vertebra. There was no documentation or evidence of a fall or trauma at the time of the hospital transfer, and the facility only became aware of the fractures upon the resident's return from the hospital. According to the facility's abuse prevention policy, injuries of unknown origin must be reported immediately, but no later than two hours after the allegation is made if abuse or serious injury is involved, or within 24 hours if not. The facility submitted the initial report to the State Agency one day after learning of the fractures, rather than within the required 24-hour timeframe. The final investigation report did not determine how the injuries occurred. This failure to report the injury of unknown origin in a timely manner was not in accordance with the facility's policy.