Failure to Report Injury of Unknown Origin with Fracture and Head Injury
Penalty
Summary
The facility failed to ensure that an injury of unknown origin involving a resident was reported immediately to the state agency and other required authorities, as required by facility policy and regulation. During rounds, the ADON found Resident #9 in bed in an abnormal position, with the resident’s head at the foot of the bed. The resident had extremely limited mobility at baseline and required assistance with transfers, and had a history of removing their oxygen, typically set at 2–3 liters. On assessment, the resident was noted to have temporal swelling, EMS was contacted, and the resident was transferred to the hospital. Hospital evaluation confirmed a rib fracture and head injury consistent with a fall, and the fall was unwitnessed. The resident was confused and unable to clearly describe how the fall occurred. The ADON reported the incident to the DON and notified the resident’s family member. The DON acknowledged awareness of the incident and stated it was discussed in a morning administrative meeting, but there was uncertainty about whether it should be reported to the state. The DON indicated she was still getting used to the reporting process and had informed the Administrator. The Administrator stated that reporting decisions were based on whether the cause of the incident was unknown and that if staff believed they knew how an incident occurred, it might not be considered reportable. He acknowledged that the resident sustained a fracture but did not complete reporting because staff believed they understood how the fall occurred, and he did not personally interview the resident, relying instead on staff reports. Facility policy on Abuse & Neglect required that all alleged or suspected violations involving mistreatment, neglect, abuse, injuries of unknown origin, and misappropriation of resident property be investigated and reported immediately to the state agency complaint hotline, and that injuries of unknown origin or suspicious injuries be immediately investigated to rule out abuse.
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