Failure to Timely Report Injury of Unknown Origin Involving Serious Bodily Injury
Penalty
Summary
The facility failed to comply with abuse reporting requirements by not submitting an initial and final report to the State Agency within required timeframes for an injury of unknown origin involving a resident who sustained a serious bodily injury. The resident, an older adult admitted for therapy and medical management with multiple diagnoses including end stage renal disease, difficulty walking, cognitive communication deficit, adult failure to thrive, and a stage 2 sacral pressure ulcer, complained of hip pain. According to the DON, the resident’s daughter reported that the resident’s hip did not look right, and the resident went to therapy but complained of pain to an agency nurse, who notified the unit manager. The unit manager obtained orders for an X-ray and PRN Tylenol. The daughter did not want to wait for the X-ray provider and requested that the resident be sent to the hospital, and the resident was transferred per family request. Progress notes show that the family requested transfer to the hospital for a dislocated hip, and later documentation from the ER indicated the resident was admitted with a right hip fracture. An incident report dated the day after the transfer identified the event as an injury of unknown origin and documented that there had been no fall or injury at the facility since admission and that an investigation was initiated. The initial report listed the date and time staff became aware of the incident as that same morning and indicated it was sent to the State Agency at 11:00 a.m. The final report for the same incident was not sent until a later date, which coincided with the day the surveyor requested the report. When the surveyor discussed this with the Administrator, she stated that she had forgotten to send the final report, despite having completed it. This sequence of events shows the facility did not adhere to its own abuse and retaliation policy, which requires all allegations of abuse, including injuries of unknown origin, to be reported to the State Agency immediately, not exceeding two hours after receipt, with a final investigation submitted within five working days.
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