Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
A resident with diagnoses including dementia, anemia, and non-thrombocytopenic purpura, who was severely cognitively impaired and dependent for care, was observed to have a large area of bruising and swelling on the right upper extremity. The injury, which included a skin tear and discoloration from the hand to the elbow, was first noted by staff, and the physician and family were notified. Facility documentation indicated that the injury was of unknown origin, and an investigation was not initiated at the time of discovery. Despite facility policy requiring prompt reporting of injuries of unknown origin to the State Agency (SA) within the required time frame, the Director of Nursing Services (DNS) did not report the injury to the SA while the investigation was ongoing. The DNS acknowledged responsibility for timely reporting but cited workload as a reason for the delay. The injury was ultimately reported to the SA several days after it was first identified, outside of the required reporting window.