Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an injury of unknown origin for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident, who had a primary diagnosis of dementia, was found with bruising to the right forehead, right eye, bridge of nose, and slight bruising under the left eye. The injury was discovered in the morning, and the resident was evaluated by a nurse practitioner and sent to the emergency department for further assessment. The responsible party was notified, and the resident returned to the facility later that day with no abnormal findings from the CT scan. Despite the facility's policy requiring immediate reporting of injuries of unknown origin to the Department of Health within two hours, the initial report was filed more than three hours after the injury was noted. Additionally, the facility did not have a completed investigation, witness statements, or investigation notes on file as required by their policy. The current administrator confirmed these documentation gaps and stated that the expected procedures were not followed at the time of the incident.