Failure to Timely Investigate and Report Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to conduct a timely investigation and self-report an incident following the discovery of an injury of unknown origin for a resident with severe cognitive impairment and multiple complex medical conditions, including Alzheimer's dementia, Trisomy 21, and epilepsy. The resident, who was nonverbal and required significant assistance with activities of daily living, was first observed with a bruise above the left eye during a routine skin evaluation. Despite the resident's inability to explain the injury and no staff witnessing an incident, the injury was not immediately classified or investigated as an injury of unknown origin. Subsequent documentation showed that the resident developed additional injuries, including bilateral periorbital bruising and a swollen, painful left hand, which prompted further medical evaluation and imaging. The facility did not initiate a self-reported incident (SRI) or a formal investigation until multiple injuries were observed several days later. Staff interviews confirmed that the initial injury was reported internally but not escalated or reported to external authorities as required by facility policy and state regulations for injuries of unknown source. The facility's policy mandates immediate reporting and investigation of all injuries of unknown origin, especially when the resident cannot explain the injury and no witnesses are present. However, the investigation and reporting process was delayed until additional injuries were identified, and there was no evidence that an investigation was started after the first injury was noted. This lapse had the potential to affect all residents in the facility, as timely identification and investigation of such incidents are critical for resident safety and regulatory compliance.