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 agency as required by its Abuse and Neglect Policy. A resident was observed by an LPN to have a large, circular red/purple bruise approximately six inches in diameter on the left mid-back during a transfer to a stretcher. The LPN noted that the resident had been on Eliquis, a blood thinning medication, which had been placed on hold, and that there were no recent falls other than one that occurred two to three weeks prior, which the nurse did not believe was related to the bruise. The LPN reported the bruise to the Director of Nursing (DON), stating that the bruise appeared overnight and its cause was unknown. Despite the facility's policy requiring immediate reporting of injuries of unknown origin to the state agency, the incident was not reported. Both the DON and the facility administrator confirmed that the injury was not reported to the state agency, acknowledging that it should have been. The facility's records did not contain documentation of the required report for this incident.