Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to investigate and report an injury of unknown origin for one sampled resident. The resident was admitted with diagnoses including diabetes mellitus, hemiplegia, and hemiparesis following a cerebral infarction, and was documented on the MDS as dependent on staff for ADLs and transfers. A History and Physical dated 4/19/2026 indicated the resident had capacity to understand and make decisions. On 12/21/2025 at 9:14 am, a bilateral hip X-ray showed a suspected acute right femur fracture. A Change in Condition Evaluation completed at 1:56 pm the same day documented the suspected right femur fracture and the primary physician’s recommendation to transfer the resident to an acute care hospital for further evaluation. Nursing notes show the resident was picked up by ambulance and transferred out at 4:20 pm. Subsequently, an X-ray at the acute care hospital on 12/22/2025 at 9:11 am confirmed an acute right femur fracture. Despite these findings, 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, police, or State Survey Agency within two hours of obtaining the X-ray results. The DON acknowledged the facility did not follow its policy, dated 9/2022, which requires that all reports of resident abuse, including injuries of unknown origin, be reported to local, state, and federal agencies as required and be thoroughly investigated by facility management, with findings documented and reported.
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