Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey State Department of Health (NJDOH) for an incident involving a resident on 6/4/24. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had multiple diagnoses including legal blindness, contractures, and spinal stenosis. The resident was dependent on assistance for daily activities and had an unwitnessed fall, resulting in a small abrasion on the forehead and complaints of neck pain and a headache. The resident was subsequently sent to the hospital and admitted for encephalopathy. Despite the incident, no report was filed with the NJDOH, and the facility's Director of Nursing (DON) was unable to provide evidence of prior documentation of the resident's spastic movements, which were observed but not care planned. The facility's policies on abuse prohibition and accidents/incidents require that injuries of unknown source be reported to the appropriate state and local authorities within 24 hours if they do not result in serious bodily injury. However, the DON confirmed that no report was filed for the unwitnessed injury of unknown origin. The investigation report lacked a conclusion and did not include a statement from the resident, who was incoherent at the time of the incident. The facility's failure to report the incident and document the resident's condition prior to the fall contributed to the deficiency identified by the surveyors.
Plan Of Correction
1. Corrective Action of Areas Affected: Resident #75 is [R] in the facility. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. The Director of Nursing and Administrator have reviewed incidents of unknown origin retroactive to 6/1/24 and verified other incidents have been reported as required. 3. Systemic Changes to Prevent Future Occurrences: The Director of Nursing and Administrator are reviewing incidents, including those of unknown origin at daily Clinical Meeting to verify incidents meeting reporting criteria are reported to the appropriate agencies. The Director of Nursing and Administrator report events as per guidelines and have been re-inserviced by the Market Clinical Advisor on reporting incidents of unknown origin. 4. Monitoring of Corrective Action: The Director of Nursing or designee will complete an audit of incidents weekly x4 weeks, then monthly x2 months to verify incidents meeting reporting criteria are reported to the appropriate agencies. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.