Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than two hours after the allegation was made. Specifically, a resident with severe cognitive impairment, as indicated by a BIMS score of 00 and diagnoses including dementia, diabetes, and depression, was found to have a bruise and a skin tear of unknown origin on her left arm. The injuries were first reported by a family member to the charge nurse, who documented the findings in the resident's progress notes. Despite the documentation of the injuries, there was no evidence that the incident was reported to the state agency as required. The facility's records did not show any incident report, physician orders for monitoring or treating the injuries, or updated care plans reflecting the new injuries. Interviews with nursing staff and facility leadership revealed that the required notifications and investigations were not completed. The charge nurse, who was new at the time, reported the injuries to the Administrator and DON but did not complete an incident report or follow all notification protocols. The Administrator and DON did not recall being notified or investigating the incident, and the event was not identified during routine reviews of the 24-hour report. The facility's policy required immediate reporting and investigation of all allegations of abuse, neglect, or injuries of unknown origin, but this process was not followed in this case. Staff interviews indicated a lack of clarity and consistency in following the reporting procedures, and the incident was ultimately overlooked by facility management. As a result, the required reporting to the state agency did not occur, and the incident was not properly investigated or documented according to facility policy.