Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its own policies and regulatory requirements for timely reporting of suspected abuse, neglect, or injury of unknown origin to the State Agency (SA) for one resident. A resident with severe cognitive impairment, dementia, and a history of falls experienced an unwitnessed fall from a Broda chair while unattended in the day room. Although no new injury was noted from this fall, the resident's right hand remained swollen from a previous finger fracture, the cause of which was undocumented and unwitnessed. Interviews with staff, including a nursing assistant and the DON, revealed a lack of awareness regarding the resident's recent falls and the origin of the hand injury. The DON was unable to provide documentation of the incident or evidence that it had been reported to the SA, as required by facility policy. The administrative consultant and facility administrator both acknowledged that the injury of unknown origin should have been investigated, documented, and reported to the SA, but confirmed that this process was not completed. Review of facility policies and posted guidance indicated that suspected abuse or reportable incidents, including injuries of unknown origin, must be reported to the SA within two hours of discovery. The facility's internal investigation policy outlined steps for conducting investigations, but in this case, there was no adequate investigation or timely reporting of the incident involving the resident's hand injury, resulting in noncompliance with both facility policy and regulatory requirements.