Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the California Department of Public Health (CDPH) for one of three sampled residents. The resident had dementia, hypertension, and hyperlipidemia, and an H&P documented that the resident did not have capacity to understand or make medical decisions. An MDS assessment showed moderate cognitive impairment and a need for staff assistance with eating, toileting, and personal hygiene. On 3/6/2026, an SBAR documented that the resident was noted with weakness while walking in the dining hall for lunch, required assistance back to her room, and complained of left hip and leg pain rated eight out of ten. The SBAR also indicated the resident complained of left hip pain but was unable to give a complete description of what happened to cause the pain, and while an X-ray was being completed, the resident stated she had a fall but could not provide details of how it occurred. On 3/9/2026, an IDT progress note documented X-ray findings of an acute complete femoral neck fracture with partial displacement of the left hip, and the physician ordered transfer to a general acute care hospital for further evaluation and treatment. In an interview, RN 1 stated that on 3/6/2026 the resident was alert and oriented to name only and unable to explain how the fall occurred, and that details such as when or where the fall occurred were unknown. In a concurrent interview and record review, the DON stated the fall was unwitnessed, the details were unknown, and the resident was unable to explain the circumstances. The facility’s abuse, neglect, exploitation, or misappropriation reporting and investigating policy required that suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source be reported immediately to the administrator and to state officials, including the state licensing/certification agency. The DON acknowledged that failure to report this injury of unknown origin delayed investigation by CDPH and placed residents’ safety at risk.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.