Failure to Immediately Report Injury of Unknown Origin Suspicious for Abuse
Penalty
Summary
Facility staff failed to immediately report an injury of unknown origin, suspicious for abuse, involving a resident with severe cognitive impairment and multiple medical conditions, including dementia, hypertension, and depression. The resident was found with moderate bruising on the face and neck, as well as a skin tear, with no documented cause or recent incident to explain the injuries. The nursing note indicated that the resident was unable to communicate what had happened due to baseline confusion, and the Director of Nursing and emergency contact were notified. However, there was no evidence that the injury was immediately reported to the state agency or adult protective services (APS) as required. Facility documentation showed inconsistencies and delays in reporting, with the initial incident form completed but lacking confirmation of submission to the appropriate authorities. The state agency had no record of receiving the initial report, and APS was not notified until several days after the incident. Interviews with the current administrator and DON confirmed the absence of fax or email confirmations and an inability to explain the conflicting report dates. The facility's policy required immediate reporting of such incidents, but this was not followed in this case.