Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation and timely reporting of an injury of unknown origin for one resident. According to the facility's Abuse Prohibition policy, any injury or suspected neglect must be investigated within twenty-four hours, documented, and reported to the State Agency, with a completed investigation summary submitted within five days. In this case, a resident was discharged to the hospital due to uncontrolled pain and was later diagnosed with a right scapula fracture. Upon return to the facility, the resident required orthopedic follow-up and had his right arm immobilized in a sling. Despite receiving notification from the hospital regarding the fracture, there was no evidence that the facility initiated an investigation within the required timeframe, submitted a report to the State, or completed the mandated five-day follow-up. Interviews with the DON and Administrator revealed that neither was aware of the fracture diagnosis when the resident returned, and both acknowledged that the injury should have been investigated and reported as required by policy. The deficiency centers on the facility's failure to respond appropriately to an injury of unknown origin by not initiating, documenting, or reporting the incident as mandated.