F0609

D

Failure to Timely Report Injury of Unknown Origin Involving Finger Fracture

Reedsburg, Wisconsin Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report an injury of unknown origin, later identified as a closed nondisplaced fracture of a resident’s left pinky finger, to the State Survey Agency as required by policy and regulation. The facility’s written policy on Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation states that all allegations of abuse, neglect, mistreatment, injuries of unknown source, or misappropriation of property must be promptly investigated and reported to appropriate agencies in accordance with state and federal laws. The policy further specifies that serious injuries must be reported to law enforcement no later than two hours after discovery and nonserious injuries no later than 24 hours after discovery, and that injuries of unknown origin are to be treated as potential misconduct requiring immediate reporting and investigation.

The resident involved had significant medical and cognitive impairments, including cerebrovascular disease, unspecified severe dementia with anxiety, and bilateral osteoarthritis of the hips. A Significant Change MDS dated 1/22/26 documented severe cognitive impairment with a BIMS score of 00, indicating the resident was unable to reliably report or explain events. On 12/19/25, nursing documentation noted a change in the appearance of the resident’s left pinky finger, including a large, red, warm hematoma on the lateral aspect of the finger. The POA and on-call physician were notified, and the resident was transferred to the emergency department for evaluation of the hematoma and possible abscess.

Hospital records from that same day documented that the resident presented with hand pain and a swollen left pinky with purulent drainage, with the source of injury unclear. Radiologic imaging showed a possible nondisplaced fracture of the distal phalanx of the left little finger, and the discharge diagnosis included an abscess and a closed nondisplaced fracture. During the survey, an LPN reported that the finger had been broken about a month earlier and that she was not aware of how the fracture occurred, and the DON confirmed there was no incident report or weekly wound assessment documentation for the injury. The Nursing Home Administrator acknowledged in interview that an injury of unknown source should be reported to the state and that this resident’s fracture should have been reported and investigated to determine the cause, but this was not done within the required timeframe, resulting in the cited deficiency.