Failure to Immediately Report Injury of Unknown Origin
Penalty
Summary
Facility staff failed to follow abuse prevention policies regarding the immediate reporting of an injury of unknown origin for one resident. The resident, who had multiple diagnoses including dementia with severe cognitive impairment, was found with moderate bruising on both sides of the face and neck, as well as a skin tear on the right cheek. The resident was unable to explain the cause of the injuries due to baseline confusion, and there was no documentation of a recent fall or incident that could account for the injuries. The facility's nursing note indicated that the DON and the resident's emergency contact were notified, but there was no evidence of immediate reporting to the state agency or adult protective services (APS) as required by facility policy. Facility documentation included an initial synopsis form describing the injury, but there was no confirmation that this report was sent to the state agency, APS, or the department of health professions (DHP). The state agency had no record of receiving the initial report, and there were conflicting report dates regarding notification to APS. The administrator and DON confirmed during interviews that there was no evidence of immediate notification to the required authorities, and only the final investigation findings were confirmed as submitted several days after the incident. The facility's policy required immediate reporting of such incidents, but this was not followed in this case.