F0609

D

Failure to Report Injury of Unknown Origin with Fracture to State Agency

Tallulah, Louisiana Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an injury of unknown origin with serious bodily injury to the State Survey Agency as required by state law and the facility’s own Abuse Reporting and Investigation Policy and Procedure. The policy states that all reports of abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown source must be promptly reported to local, state, and federal agencies and thoroughly investigated, and that suspicious injuries of unknown origin, including fractures in cognitively impaired residents when not witnessed, must be reported. The facility’s policy further defines injuries of unknown origin as those not observed by any person, not explainable by the resident, and suspicious due to the extent or location of the injury.

Record review showed that a resident with diagnoses including COPD, adult failure to thrive, repeated falls, generalized anxiety disorder, dementia with agitation, and delirium had severe cognitive impairment, with a BIMS score of 7, and required one-person assistance for standing and transfers. An incident report documented that this resident was found with bruising and swelling to the lower left leg in the evening, and an x-ray obtained the next day revealed acute mid and distal fractures of the tibia and fibula. The DON reported that the resident was unable to state the cause of the injury due to dementia and that the facility’s investigation could not determine a cause for the fracture, meeting the criteria for an injury of unknown origin with serious bodily injury. The Administrator, who was responsible for notifying the State Survey Agency, confirmed that the facility did not report this injury as required by the facility’s policy and state reporting requirements.