Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the California Department of Public Health (CDPH) for one resident who experienced right hip pain that was later found to be a dislocation. The resident had been admitted with a diagnosis of joint replacement surgery aftercare and had a femoral head arthroplasty. An MDS assessment indicated the resident’s cognition was intact and that she required substantial/maximal assistance with ADLs. A Change of Condition form documented that the resident complained of right hip pain with intact skin and slight swelling. A subsequent radiology report showed a superior lateral dislocation of the right hip involving the prior arthroplasty. Interviews with facility leadership confirmed that the event met the definition of an injury of unknown origin and that it was not reported to CDPH. The ADON stated there was initially no explanation for the hip pain until the X-ray showed a dislocation, at which point it became an injury of unknown origin, but it was still not reported. The Administrator also stated that because there was no reason for the dislocation, it was considered an injury of unknown origin. The DON stated she believed the resident had reported hearing a pop during a transfer to bed and therefore did not report it as an injury of unknown origin, but later acknowledged there was no report of how the injury occurred. The facility’s abuse prevention policy indicated staff are to be trained on reporting abuse, neglect, exploitation, misappropriation, and injuries of unknown sources, including to whom and when such events must be reported.
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