Delayed Reporting of Injury of Unknown Source
Penalty
Summary
The facility failed to ensure that all alleged violations involving injury of unknown source were reported immediately, as required by policy and regulation. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including dementia and diabetes, was found unable to stand on their left leg and was transferred to the hospital, where a closed left hip fracture was diagnosed. The resident was unable to explain how the injury occurred, and there was no documentation of a fall or traumatic event. Despite the facility's policy requiring immediate reporting of such incidents, the injury was not reported to the New York State Department of Health until ten days after the change in the resident's condition was observed. Record review and interviews revealed that the delay in reporting was due to a lack of immediate notification to the Director of Nursing by the nursing supervisor. The Director of Nursing only became aware of the fracture after the resident was readmitted from the hospital and subsequently reported the injury. The facility's investigation did not find evidence of abuse, mistreatment, or neglect, and there was no documentation that the fracture was pathological. However, the failure to report the injury of unknown source within the required timeframe constituted a deficiency.