Failure to Timely Report Severe Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report a severe injury of unknown origin to the State Agency, the Office of Health Care Quality (OHCQ), within the required two-hour timeframe after becoming aware of the injury’s severity. On 12/06/2025 at approximately 4:00 PM, a resident was reported to be screaming in severe pain in the left hip and was transported to a nearby hospital. The facility’s investigation file for this incident contained one on-duty staff incident statement and two staff email statements regarding the unknown origin injury. On 12/07/2025, records show that the Charge Nurse (Staff #41) and the Unit Manager (Staff #42) were informed that the hospital had diagnosed the resident with a left hip fracture. During an interview on 01/14/2026, the Charge Nurse reported that on 12/07/2025 she encountered the resident’s family picking up personal belongings and at that time learned that the resident had sustained a severe left hip fracture. In a separate interview on the same day, the Administrator confirmed that facility staff became aware of the resident’s severe injury of unknown origin on 12/07/2025. Despite this, the initial Facility Reported Incident (FRI) was not submitted to OHCQ until 12/08/2025 at 9:54 AM, which was one day after staff became aware of the severity of the injury. This delay did not comply with FRI reporting requirements that mandate immediate notification, and no later than two hours after the facility becomes aware of a severe injury.
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