Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin and did not submit an investigation to the State Agency within the required 5 working days for one resident. According to the facility's Abuse and Neglect Policy, all alleged or suspected violations, including injuries of unknown origin, were to be reported immediately to the Administrator or a delegated individual and thoroughly investigated, with results submitted to the State Agency. The policy also outlined steps to protect residents and ensure a complete review of such incidents. A review of the facility's Incident and Accident Log showed that a resident was found with bruising to both hands, identified as an injury of unknown origin. Nursing progress notes documented specific measurements of the bruises on the resident's fingers and knuckles. However, there was no evidence that this incident was reported or that an investigation was conducted and submitted to the State Agency as required. The facility Administrator confirmed that the injury was neither reported nor investigated.