Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report a significant injury of unknown origin for one resident, as required by both state regulations and the facility's own policies. A Certified Nursing Assistant notified a Registered Nurse that the resident had bruising on the upper torso. The RN documented a large green-yellow bruise on the chest between the breasts and another purple bruise on the left side of the torso next to the left breast. The resident was unable to explain how the injuries occurred and exhibited discomfort and pain during movement and touch. According to the facility's policy and state guidelines, such injuries—especially those in areas not generally vulnerable to trauma—must be reported to the state agency. Despite logging the incident in the facility's March incident log, the event was not reported to the state agency. Both the Interim Director of Nursing and the Interim Administrator acknowledged during interviews that the incident met the criteria for mandatory reporting and should have been reported according to the guidelines outlined in the Purple Book and facility policy. The failure to report the injury constituted a deficiency in the facility's abuse, neglect, and injury reporting procedures.