Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for one resident who was admitted with dementia and weakness and required two-person assistance for turning and repositioning. On a specific date, staff observed the resident with bruising and discoloration on the right lower leg, swelling around the left hand, pain at the shoulder, and additional discoloration around the chest, none of which had been present the previous day. Staff members assessed the injuries and notified supervisory staff, but did not determine the cause of the bruising, and the resident was unable to describe how the injuries occurred. Despite the concerning findings, no Facility Reported Incident (FRI) form was completed for the resident. Staff involved acknowledged that an FRI form was not filled out, and one staff member stated she had never completed such a form before. The lack of timely reporting and documentation of the injuries of unknown origin constituted a failure to follow required abuse and neglect reporting protocols.