Failure to Report and Investigate Unwitnessed Injury With Hip Fracture
Penalty
Summary
The facility failed to implement its policies and procedures related to abuse, neglect, and injuries of unknown origin by not reporting and not investigating an unwitnessed injury that resulted in a hip fracture. One resident, identified as R56, was admitted to the skilled nursing unit with diagnoses including dementia and weakness, and had a BIMS score of 12/15, indicating moderate cognitive impairment. On 01/03/24, an incident/accident report documented that R56 was observed lying on the floor with no witnesses to the event. Upon assessment, the resident complained of right leg pain and was unable to perform active range of motion without pain. Following this unwitnessed event, R56 was transferred to the hospital and underwent a right partial hip replacement due to a fracture. Despite the injury occurring under unwitnessed circumstances, the former Administrator did not complete a facility reportable incident within 24 hours. A written statement from the Executive Vice President/Chief Operating Officer and Chief Clinical Officer indicated that the former Administrator believed the fracture was related to a fall and not an injury of unknown origin. This decision was inconsistent with the facility’s Abuse Prevention Program policy, which requires that injuries of unknown origin be reported, investigated, and managed in accordance with facility procedures and regulatory requirements.
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.