Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the state survey agency as required by its own policy and state regulations. A resident with severe cognitive impairment and multiple medical diagnoses, including atrial fibrillation and a history of bruising, was observed with significant discoloration (11 cm x 7 cm) on the right upper extremity. The injury was documented by nursing staff and reported internally to the Administrator and Director of Nursing, but no external report was made to the Illinois Department of Public Health. The facility's policy mandates that all accidents and incidents, including those of unknown origin, be reported to the department supervisor and that major injuries be reported to the state agency within 24 hours. Despite the resident's inability to explain the cause of the injury and the absence of any clear source, facility staff assumed the bruise was related to the resident's medical history and anticoagulant use. The Assistant Director of Nursing confirmed that the injury was not considered to be of unknown origin and therefore was not reported to the state agency. This omission occurred even though the facility's policy specifically requires reporting such incidents when the origin is unknown.