Failure to Timely Report Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who was observed with a discoloration on her forehead, a black eye, and swelling, to the California Department of Public Health (CDPH) as required. The resident, who had diagnoses including chronic kidney disease, dementia, hypertension, and schizophrenia, was dependent on staff for most activities of daily living and lacked the capacity to make decisions. On the morning of the incident, staff observed the resident with new bruising and swelling, but no staff member witnessed the event or could explain how the injury occurred. The resident's medical provider and family were notified, and medical interventions such as a skull x-ray and neurological checks were ordered. Multiple staff interviews revealed that the injury was first noticed during a shift change, with no prior documentation of trauma or incident. Staff members, including CNAs and RNs, stated they did not know how the injury happened, and some speculated it may have been caused by the resident hitting her head on the bed rails, though this was unwitnessed. The facility's own policy defined injuries of unknown source as those not observed or explained and considered suspicious due to their extent or location. Despite this, the required reporting to CDPH and other authorities was not completed in a timely manner. The Director of Nursing (DON) confirmed during interviews that she was unaware of the obligation to report the injury as an incident of unknown origin. Facility policies reviewed indicated that such injuries should be reported to state agencies within specified timeframes and that thorough investigations should be conducted. However, the lack of timely reporting prevented CDPH from investigating the injury promptly, constituting a failure to follow regulatory requirements for reporting suspected abuse, neglect, or injuries of unknown origin.