F0609

D

Failure to Timely Report Resident Fracture as an Unusual Occurrence

Culver City, California Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its Unusual Occurrence policy requiring that events threatening a resident’s welfare, safety, or health be reported to the California Department of Public Health (CDPH) within 24 hours. The resident involved had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, severe cognitive impairment, and dependence on staff for all ADLs, including transfers and mobility. The resident was transferred to a general acute care hospital for hypotension, desaturation, shortness of breath, fever, and further evaluation. A chest radiology report at the hospital identified a subacute displaced fracture of the surgical neck of the right humerus. The facility’s Unusual Occurrence policy, dated 3/2010, required reporting such events to CDPH within 24 hours.

The sequence of events shows that the family member learned of the right shoulder fracture from the hospital x‑ray results and then informed the DON two days after the hospital transfer. The DON and DOR reported being surprised by the fracture and indicated there had been no staff reports of falls or injuries involving the resident. The GACH social worker stated she had called the facility the day after the hospital transfer and informed a facility representative of the right shoulder fracture. Despite this information, the DON acknowledged that the facility did not report the fracture to CDPH because they did not know what had happened, even though the ADM stated that unusual occurrences were required to be reported so CDPH could determine through investigation whether the event constituted an unusual occurrence. This failure to report the fracture as an unusual occurrence within the required timeframe constituted the cited deficiency.