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F0609
D

Failure to Report Injury of Unknown Origin to State Agency

Clintonville, Wisconsin Survey Completed on 04-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an injury of unknown origin to the State Agency as required by its Abuse Prevention policy. A resident with dementia, adult failure to thrive, and on palliative care was found to have a hematoma on the left forearm, with staff and Hospice personnel unable to determine the cause of the injury. The resident had a severely impaired cognitive status, as indicated by a BIMS score of 3 out of 15, and an activated Power of Attorney for Healthcare. Progress notes documented the presence of discoloration and a large hematoma, with no complaints of pain from the resident, who was also noted to be combative with staff during care. Despite the facility's policy requiring all alleged violations, including injuries of unknown origin, to be reported to the State Agency within two hours and followed up in writing within five days, the injury was not reported. The facility conducted an internal investigation, which included input from the resident's POAHC, who stated the resident had hit their arms on the bed during a visit. However, the injury remained unreported to the State Agency, and the Director of Nursing confirmed this omission during the surveyor's interview.

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