Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the State Agency as required by regulation and by its own abuse reporting policy. A resident with dementia, severe cognitive impairment, and a right hip replacement was dependent on staff for activities of daily living. A physician progress note documented that the resident was seen for lethargy and right thigh tenderness, and an x-ray of the right femur confirmed an acute posterior dislocation of the femoral head prosthesis with inward rotation of the femur. The resident could not explain what had happened, and staff statements indicated that no one had witnessed any fall or incident involving the resident. The facility’s accident/incident report documented the date, location, and time of occurrence as unknown, and the investigative summary later concluded there was no reasonable cause to believe abuse, mistreatment, or neglect had occurred. Despite the unknown cause of the dislocated hip prosthesis and the resident’s inability to provide an account, there was no documented evidence that this injury of unknown origin was reported to the State Agency. The facility’s abuse policy defined injuries of unknown source as those not observed, not explainable by the resident, or suspicious due to extent or location, and required investigation and reporting per New York State Department of Health and CMS regulations. However, on the investigative summary, the section indicating whether the incident was reported to the Department of Health was left unchecked. In an interview, the DON stated that because the resident did not have a fracture, the incident was not reported and was not considered an injury of unknown origin, and asserted that the facility followed its protocols, even though the cause, time, and location of the injury remained unknown and the resident was not cognitively intact to explain the event.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.