Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy and procedures by not immediately reporting 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 bruise to the right eye and petechia above the eyebrow. 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 delay in reporting the injury of unknown origin lasted 44 days, and the facility did not follow its policy, which requires immediate external reporting of any allegations of abuse, neglect, or injury of unknown origin. The policy specifies that such incidents must be reported to the Department of Public Health immediately, or within two hours if serious bodily injury is suspected, and no later than 24 hours otherwise. The failure to report and investigate the incident as required affected two residents reviewed for reporting abuse and injury of unknown origin.