Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to report an injury of unknown origin to the Illinois Department of Public Health (IDPH) for a resident who was found with scattered bruising of various colors on her inner thighs. The bruises were first noticed by a CNA during routine care, and the resident, who was a standby assist and sometimes refused care, attributed the bruises to her incontinence briefs. The nurse documented the bruises, and the administrator acknowledged that the cause of the bruises could not be determined, classifying them as injuries of unknown origin. Despite this, the facility did not report the incident to IDPH as required by their own policies and state regulations. The resident involved had multiple diagnoses, including Alzheimer's disease, dementia with behavioral disturbance, diabetes, vitamin B deficiency, and was on palliative care. The administrator later reviewed hospital records and noted that the bruises appeared different over time and that the resident ultimately died after a fall and subsequent hospitalization, with a possible cause of death being an aortic dissection or aneurysm. The facility's policies required investigation and reporting of unexplained injuries, especially those in unusual locations or without a clear cause, but this process was not followed in this case.