Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident, as required by its Abuse Prevention Program and state regulations. The policy mandates that nursing staff report any appearance of bruises or injuries of unknown origin on a facility incident report, and that the Nursing Supervisor assess the resident, review documentation, and report to the administrator or designee. Additionally, the policy requires a final investigation report to be sent to the administrator and the Department of Public Health. In this case, a resident with multiple diagnoses, including encephalopathy, mild dementia, and pressure ulcers, was found to have a bruise on the right buttock, which was documented as an injury of unknown origin. The event was unwitnessed, and the resident was unable to provide details due to their condition. Despite the documentation of the injury, the administrator stated that no complete report was made and the incident was not reported to the state agency because the administrator was unaware of the injury. The lack of awareness led to the absence of an immediate investigation and failure to notify the appropriate authorities, as required by facility policy and regulation. This inaction resulted in noncompliance with the facility's abuse reporting procedures for injuries of unknown origin.