Failure to Report and Adequately Investigate Finger Fracture of Unknown Origin
Penalty
Summary
The facility failed to timely report an alleged violation involving mistreatment, neglect, or injury of unknown origin to the Iowa Department of Inspections and Appeals and Licensing (DIAL) after a resident was found to have a left middle finger fracture. The resident had severe cognitive impairment with a BIMS score of 3, diagnoses including non-Alzheimer’s dementia, polyneuropathy, and macular degeneration, and required substantial to maximal assistance with all ADLs and two staff with a full-body mechanical lift for transfers. The care plan directed staff to protect the resident’s arms with long sleeves, use pillows to prevent bumping arms and feet, and observe and report changes to the physician as needed. On one morning, staff notified the nurse that the resident’s left hand was significantly swollen. The nurse documented non-pitting edema of the left hand without pain on touch, removed the arm protector due to circulatory restriction, and elevated the arm on a pillow. Later that night, the nurse faxed the physician about the significant edema, noting no pain with movement and no edema elsewhere, and received an order to elevate the arm above heart level and a question about obtaining an X-ray. An X-ray obtained the next day showed an acute nondisplaced fracture of the third middle phalanx of the left hand. Nursing documentation reflected that the resident did not cooperate during splint application to the fractured finger. Despite the confirmed fracture and the lack of a witnessed cause, the facility did not report the injury of unknown origin to DIAL within 2 hours as required by its abuse prevention, identification, investigation, and reporting policy. The facility’s investigation consisted of a brief, undated, one-page document stating that no staff witnessed an incident and that the resident frequently rubbed his fingers together, put his hands in his shirt, and had degenerative changes on X-ray. Staff interviews indicated they did not know how the fracture occurred and suggested possibilities such as the resident twisting his own fingers or getting a finger caught in side rails, but no definitive cause was identified. The Interim DON acknowledged that a more thorough investigation should have been conducted, while the Administrator concluded the fracture did not meet criteria for reporting, resulting in the failure to report an injury of unknown origin as required by facility policy.
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