F0609

E

Failure to Timely Report and Investigate Injuries of Unknown Origin Resulting in Fractures

Liberty, New York Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report and investigate injuries of unknown origin that resulted in fractures for two residents, as required by 10 NYCRR 415.4(b)(2). For the first resident, who was severely cognitively impaired and had osteoporosis and other diagnoses including muscle weakness and glaucoma, staff documented that the resident returned from eye surgery with instructions not to ambulate without assistance and with an alarm placed on the bed. On a subsequent day, an Accident and Incident report noted a light to dark purple bruise, approximately the size of a 50‑cent piece, on the resident’s right hip. The resident was unable to describe what happened, reported pain, and could not stand as they normally could. The resident was sent to the hospital, and imaging later showed a displaced acute traumatic fracture of the right femoral neck. There was no indication in the record of how the injury occurred, no documented facility investigation into the cause, and no report submitted to the New York State Department of Health within the required timeframe.

The same resident’s incident documentation showed that the facility’s internal policy required the Nurse Supervisor/Charge Nurse or department supervisor to complete an incident/accident report and submit it to the Director of Nursing within 24 hours, and for the Director of Nursing to ensure the Administrator received a copy. The incident report for this resident included a brief description of the bruise and immediate actions such as notifying the provider, DON, and family, and sending the resident to the emergency department. However, the report lacked statements from staff or others, and there was no documented investigation into the circumstances surrounding the injury, despite the x‑ray impression describing a displaced acute traumatic fracture of the right femoral neck. During interview, the Medical Director stated they had no idea what caused the incident, would have expected more investigation and a look‑back of staff who provided care, and acknowledged the possibility of a fall or a fracture related to osteoporosis, but there was still no documented determination of cause or timely reporting to the Department of Health.

For the second resident, who was severely cognitively impaired, incontinent, used a wheelchair for mobility, and required assistance for transfers and bed mobility, staff identified a large purple bruise with mild swelling on the left lower leg. The resident showed mild discomfort on palpation and later complained of pain, saying "Ow, ow, that hurts," according to a CNA. The Infection Control Nurse completed an accident/incident report describing the bruise and mild discomfort, and documented that a root cause analysis determined the bruise was from bumping the Hoyer during transfer, yet there were no supporting statements in the report. A nurse practitioner assessed the bruise as a contusion and planned monitoring. The Medical Director later ordered an x‑ray, which was not completed at the facility, and the resident was eventually sent to the emergency department, where a fracture of the left tibia and fibula was diagnosed. The DON later stated they did not know how the Infection Control Nurse concluded the bruise was from bumping the Hoyer and did not know why they were not made aware earlier. The injury of unknown origin was reported to the Infection Control Nurse on one date, but the DON did not submit a report to the New York State Department of Health until several days later, outside the required immediate reporting timeframe for alleged abuse, neglect, or injuries of unknown origin resulting in serious bodily injury.