Failure to Report Injury of Unknown Origin as Required by Abuse and Unusual Occurrence Policies
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse reporting and prevention policies by not reporting an injury of unknown origin for one resident to required external agencies. The resident had diagnoses including polyosteoarthritis, dementia, and muscle weakness, and an H&P documented that the resident did not have capacity to understand and make decisions. An MDS assessment showed moderate cognitive impairment, dependence on staff for all ADLs, need for assistance with rolling, and impairments in both upper and lower extremities. A change in condition note documented swelling and ecchymosis of the resident’s left arm, and a subsequent X-ray identified a displaced fracture at the surgical neck of the left humerus, with the resident later transferred to a general acute care hospital for treatment. Staff interviews revealed that a CNA notified an LVN about discoloration of the resident’s left arm, and the LVN observed discoloration in the upper and lower parts of the arm. The LVN acknowledged that, in the event of a change in condition, she should have notified the DON but did not do so. The DON stated that an unusual occurrence includes suspected abuse such as an injury of unknown origin, and that the facility’s protocol required the LVN to report such events to the DON, the administrator, CDPH, the ombudsman, and, if needed, law enforcement and APS within specified time frames. The DON stated that serious injuries such as accidents and fractures are unusual occurrences that must be reported to appropriate officials and CDPH within two hours, and that when the LVN learned of the fracture, she should have informed the DON. The administrator stated that an unusual occurrence is an event that cannot be explained or have its root cause identified, and that for unusual occurrences and abuse allegations, the facility is to report the incident and notify the ombudsman, police, and CDPH within two hours, followed by an investigation within five days. The administrator stated they did not know how the resident’s left arm was broken, that this was an injury of unknown origin, and that it would have been reportable. Review of the facility’s written policies confirmed that all reports of resident abuse, including injuries of unknown origin, must be reported immediately to the administrator and to state licensing/certification and other required agencies within defined time frames, and that unusual occurrences affecting health, safety, or welfare must be reported by telephone within 24 hours and in writing within 48 hours. Despite these policies, the injury of unknown origin and resulting fracture were not reported as required, leading to the cited deficiency.
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