Failure to Report Injury of Unknown Source as Required by Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy and procedure when it did not report an injury of unknown source for a resident. The resident, who had a history of hemiplegia, hemiparesis following a stroke, dysphagia, and was chronically bedbound, was found with discoloration and swelling on the right side of the face and ear. Multiple staff members, including nurses and the assistant director of nursing, observed the injury but could not determine its cause. The resident was able to communicate but was unaware of how the injury occurred, and there were no documented falls or behavioral incidents that could explain the injury. Despite the facility's policy requiring immediate reporting of injuries of unknown source to state agencies, law enforcement, and the ombudsman, the injury was not reported to any of these authorities. Staff interviews revealed that the incident was discussed internally, with some staff assuming the injury was caused by a feeding pump falling on the resident, although no one witnessed this event and some staff questioned the plausibility of this explanation given the resident's physical limitations. The interdisciplinary team reviewed the case days after the initial discovery, but the possible contributing factors were not documented, and the injury was not care planned. Key staff members, including the DON, ADONs, and the administrator, confirmed that the injury was not reported externally because they believed the cause had been determined or deferred the decision to others. The facility's social services staff was not informed of the incident, and several nurses and CNAs expressed uncertainty about reporting requirements, with some believing it was the administration's responsibility. The facility's policy clearly states that all injuries of unknown source must be reported to the appropriate agencies within 24 hours, but this was not followed in this case.