Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report and investigate an injury of unknown origin for one of ten sampled residents, as required by its abuse, neglect, exploitation, or misappropriation reporting and investigating policy. The resident was admitted with diagnoses including diabetes mellitus, hemiplegia, and hemiparesis following a cerebral infarction, and was documented as dependent on staff for ADLs and transfers. A bilateral hip X-ray obtained on 12/21/2025 at 9:14 a.m. showed a suspected acute right femur fracture. A Change in Condition Evaluation completed at 1:56 p.m. the same day documented the suspected right femur fracture and a physician recommendation to transfer the resident to an acute care hospital for further evaluation. Nursing documentation indicated the resident was transported by ambulance to the hospital at 4:20 p.m. Subsequent hospital imaging on 12/22/2025 at 9:11 a.m. confirmed an acute right femur fracture. The DON stated during interview that the facility did not conduct an investigation to determine how the resident sustained the right femur fracture and did not report this injury of unknown origin to the local Ombudsman, the Police, or the State Survey Agency within two hours of obtaining the X-ray results, as required by the facility’s policy. Review of the written policy dated 9/2022 showed that all reports of resident abuse, including injuries of unknown origin, were to be reported to local, state, and federal agencies as required by regulations and thoroughly investigated, with findings documented and reported. The DON acknowledged the facility did not follow this policy regarding the resident’s injury of unknown origin.
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