Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy and did not investigate an injury of unknown origin involving two residents. One resident reported being struck in the face with a shoe by another resident, resulting in a visible bruise and petechia. The incident was reported to the Assistant Administrator, who observed the injury but did not report it to the State Department or initiate an investigation as required by facility policy. The Assistant Administrator also did not consult the Administrator for guidance and assumed the matter was resolved by separating the residents involved. There was no documentation of the injury in the resident's medical record, and the Administrator was unaware of the incident until informed by surveyors. The facility's abuse policy requires immediate external reporting and investigation of any allegations or suspicions of abuse, neglect, or injuries of unknown origin. Despite these requirements, the injury was not reported or investigated for 44 days. The resident's family member confirmed that the incident had been reported to him and expressed concern that it should have been investigated. The lack of timely reporting and investigation represents a failure to adhere to established protocols for resident safety and abuse prevention.