Failure to Timely Report Resident Fracture to State Agency
Penalty
Summary
The facility failed to report a resident’s fracture to the State Agency within the required timeframe, contrary to its Accidents and Incidents policy. The policy, revised on 1/26, requires that accidents and incidents, including injuries of unknown origin, be reported to the department supervisor with an Accident/Incident Report completed on the shift of occurrence, and that the DON or designee report any accident or incident involving a major injury to the State Agency within 24 hours. Nursing progress notes show that on 11/29 at 3:04 AM, a resident who is dependent for all transfers and cognitively intact complained of pain above the left knee and was sent to the hospital, where pain medications were administered and an X-ray resulted in a diagnosis of a left medial collateral ligament sprain before the resident returned at 6:00 AM. On 12/11, after an orthopedic visit and CT scan of the left knee, the resident was diagnosed with a left knee fracture. Despite this fracture diagnosis, the DON confirmed on 2/9 that no reportable incident was sent to the State Agency, and the Administrator confirmed that the fracture identified on 12/11 was not reported, resulting in noncompliance with required reporting procedures. The deficiency centers on the facility’s inaction in failing to recognize and report the fracture as a reportable major injury once it was identified by CT scan, despite clear policy requirements and the resident’s dependence for transfers. Surveyor interviews with the DON and Administrator confirmed that the incident was not reported to the State Agency as required.
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