Failure to Timely Report Injury of Unknown Origin and Hospital Findings
Penalty
Summary
The facility failed to report an allegation of injury of unknown origin for a resident who was cognitively impaired and had multiple medical conditions, including long-term use of anticoagulants. The resident was re-admitted to the facility with documented bruising on her arms, legs, and thighs, but there was no documentation of bruising or bleeding in the vaginal or perineal area in the facility's records. During a subsequent hospitalization, an ER nurse identified bleeding and bruising in the resident's vaginal and perineal area, as well as additional bruising on the right thigh, and communicated these findings to the facility nurse. The facility nurse stated she was unaware of the bruising and bleeding in those areas and did not immediately report the information to the abuse coordinator or the state agency. Interviews with facility staff revealed that the wound care nurse had observed bruising on the resident's extremities and groin area upon re-admission and reported this at a morning meeting, but did not observe vaginal bleeding. The nurse in charge at the time of the resident's transfer to the hospital acknowledged being informed by the ER nurse about the bruising and bleeding but delayed notifying the Director of Nursing and did not report the incident to the abuse coordinator or state agency as required. The Director of Nursing and Administrator both confirmed they were not notified about the hospital's findings of vaginal bleeding and bruising, and facility policy requires immediate reporting of any suspected abuse, including injuries of unknown origin. Facility policies reviewed indicate that all incidents, allegations, or suspicions of abuse, neglect, or injuries of unknown source must be reported immediately to the administrator and appropriate authorities, with initial reporting to the state agency required within two hours if abuse or serious bodily injury is suspected. In this case, the failure to promptly report the injury of unknown origin and the findings communicated by the hospital staff constituted a deficiency in the facility's abuse reporting procedures.