Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in accordance with its abuse policy and procedure for one of three sampled residents. A resident with Huntington's Disease and severe cognitive impairment was found with discoloration around the right eye, which was not reported to the California Department of Public Health (CDPH) and adult protective services until two days after the injury was discovered. The injury was unwitnessed, and the resident was unable to explain how it occurred, meeting the criteria for an injury of unknown source. Staff interviews revealed that multiple CNAs and LVNs observed the injury but did not immediately notify the abuse coordinator or administrator as required by facility policy. There was confusion among staff regarding who was responsible for reporting, and documentation was lacking to show timely notification to the appropriate authorities. The Director of Nursing (DON) and other staff acknowledged that the facility's policy required immediate reporting of suspected abuse or injury of unknown source, but this was not followed in this case. The facility's own policy and the State Operations Manual both require that injuries of unknown source be reported immediately to the administrator and relevant agencies. In this incident, the report was not made to CDPH and the ombudsman until two days after the injury was discovered, and there was no documentation of timely notification to law enforcement. This delay resulted in a postponement of the investigation into the cause of the resident's injury.