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F0609
D

Failure to Timely Report Injury of Unknown Origin

Mukwonago, Wisconsin Survey Completed on 05-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely reporting of an injury of unknown origin for a resident who was severely cognitively impaired. The resident was found with a new bruise on the left forearm, which was first noticed by a CNA. The resident was unable to clearly recall how the bruise occurred, providing inconsistent explanations, and staff interviews did not reveal any clear cause. The CNA who discovered the bruise promptly notified a nurse, and the incident was assessed and documented, with the resident’s Power of Attorney and physician being notified. According to facility policy, any incident or allegation considered reportable must be initially reported to the State Agency immediately or within 24 hours, with a follow-up investigation submitted within five working days. In this case, the Nursing Home Administrator (NHA) was made aware of the bruise and conducted interviews with the resident and staff, as well as a review of the resident’s environment. The NHA determined that no abuse had occurred and that the injury was likely accidental, possibly related to a malfunctioning dresser drawer or contact with a transfer device. However, the NHA encountered technical difficulties with the reporting system, including an expired account and issues submitting the required documentation. Despite attempts to notify the State Agency via email and eventually submitting the final investigation report, the required five-day follow-up report was not submitted within the mandated timeframe. The NHA acknowledged the delay and was unable to provide evidence of timely submission. The surveyor confirmed that the final investigative findings were not reported to the State Agency within the required five working days, constituting a deficiency in the facility’s abuse, neglect, and incident reporting procedures.

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