Failure to Thoroughly Investigate Severe Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate a severe injury of unknown origin sustained by Resident #208. According to the Facility Reported Incident file, an initial report was submitted to the State Agency on 12/08/2025 regarding an incident that occurred on 12/06/2025 at approximately 4:00 PM, when the resident was reported to be screaming in severe left hip pain and was transported to a nearby hospital. Hospital records from 12/07/2025 indicated that the resident had a left hip fracture. The facility’s investigation file contained only one on-duty staff incident statement and two staff email statements related to the event, with no further documented investigative steps. On 12/07/2025, Charge Nurse Staff #41 learned from the resident’s family, who were picking up personal belongings, that the resident had sustained a severe left hip fracture, but she did not notify the Administrator until 12/08/2025 and did not initiate further staff or resident interviews. During an interview, the Administrator reported that Unit Manager Staff #42 withheld information about the severe injury of unknown origin and acknowledged that, despite the severity of the injury, no thorough investigation was conducted. The Administrator confirmed that interviews with staff working the relevant shift and residents on the same floor were not completed, resulting in an incomplete investigation into the cause of the resident’s severe injury.
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