Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident with severely impaired cognition and a history of erratic movements. On 3/4/25, an Accident/Incident Report documented that the resident was observed with discoloration on the right side of their face. This was not reported to the state agency as required. The resident had a previous incident on 2/18/25 where the bed controls swung into their face, but no injury was noted at that time. The Director of Nursing initially attributed the bruising to this earlier incident, despite the time lapse and lack of documented evidence of bruising between the two dates. Interviews with staff revealed that the bruise was first noticed on 3/4/25, and the Nurse Practitioner confirmed it was of unknown origin. The Director of Nursing acknowledged that the incident should have been reported within two hours and admitted that Incident Reporting In-Service had not been conducted. The failure to report the injury of unknown origin was a deficiency in the facility's compliance with state regulations.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 F609 I. Immediate Correction: 1) Resident # 10 was assessed by the MD and no untoward persisting effects of the bruise on the resident’s face were noted. 2) Resident # 10 was assessed by the SWD and no signs of psychosocial distress were noted. 3) The IDT Team reviewed and updated Resident # 10 CCP and CNAAR for specific interventions - The Placement of the bed, TV remote are all secure and don’t pose a risk to the resident or environmental hazard. II. Identification of Others: 1) The facility respectfully states that all residents were potentially affected. 2) All incidents and accidents for the preceding 30 days will be reviewed to ensure that any incidents of unknown origin were reported to NYSDOH. No other issues were identified. III. Systemic Changes: 1) The Policy and Procedure for Abuse Prevention was reviewed by the Administrator in conjunction with the DON and is in compliance. 2) Inservice education will be provided for all nursing staff on reporting requirements related to reporting violations involving abuse to the NYS DOH. 3) Highlights of the Lesson Plan include: - The facility staff must report all alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property, immediately to the Administrator/DNS. - Upon notification the DON/Administrator must report alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property immediately to the NYS DOH. - As per CMS 42CRF 483.12(c) the reporting definition “immediately” is defined as: 1) 2 hours if the alleged violation involves abuse or results in serious bodily injury. 2) 24 hours if the alleged violation does not involve abuse and does not result in serious injury. - As per Federal regulation 483.12(b)(5) all reasonable suspicions of crimes and/or suspicious incidents resulting in serious bodily injury must be reported to the local law enforcement within two hours. - Any reasonable suspicion of a crime not resulting in serious injury must be reported to law enforcement within 24 hours. - The Facility procedure for Staff to notify Administrator/DON immediately of any incidents involving alleged abuse or serious injuries immediately 24hrs day/7 days weekly and the responsibility of the DON or Administrator/designee to report to NYS DOH to comply with reporting requirements. IV. Quality Assurance: 1) An audit tool was developed to monitor the facility’s compliance with ensuring that all incidents and accidents are investigated, and injuries of unknown origin are reported timely as per NYS DOH and Federal reporting guidelines. 2) 5 Random Accident and Incidents will be audited by DON/Designee weekly for 4 weeks and monthly for 11 months. Any identified issues will be immediately corrected. 3) Findings will be reviewed at QA Meeting to monitor sustainability. Responsible for this FTag: DON