Failure to Report Injury of Unknown Origin to State Survey Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Survey Agency (SSA) as required by both regulation and facility policy. A resident with multiple complex medical conditions, including hemiplegia, chronic kidney disease, epilepsy, atrial fibrillation, mild cognitive impairment, and chronic pulmonary embolism, was found to have a large, painful hematoma with bruising on the right forearm during a medication pass. The resident, who was dependent on staff for most activities of daily living and had impaired cognition, was assessed and sent to the emergency department for evaluation at the physician's direction. Physician orders were subsequently written to monitor the injury and observe for signs of bleeding due to anticoagulant use. Despite the facility's policy requiring immediate reporting of injuries of unknown source to the SSA, review of the Electronic Information Dissemination and Collection (EIDC) system showed no evidence that a Self-Reported Incident (SRI) was submitted for this event. The Director of Nursing confirmed in an interview that the incident was not reported as required. The failure to report was identified during a review of medical records, staff interviews, and policy review, and affected one of two residents reviewed for abuse in a facility with a census of 120.