Failure to Timely Report and Document Alleged Abuse and Injury of Unknown Source
Penalty
Summary
The facility failed to immediately identify and report an allegation of abuse involving a resident who was found with unexplained bruising under the right eye. The bruise was first noticed by a CNA and documented by a nurse during the day shift, but no nurse's notes were entered on the day the injury was observed. A late entry was made two days later, indicating the presence of the bruise and an order to monitor the area, but without documenting the cause, as the resident was unable to verbally express it. The Director of Nursing confirmed that the nurse did not submit a federal report at the time because she did not consider the injury to be abuse, instead following the physician's order to monitor the bruise. The facility's policies require that all alleged violations of abuse, neglect, exploitation, or mistreatment—including injuries of unknown source—be reported immediately, but not later than two hours, to the appropriate authorities. Despite this, the Director of Nursing was not notified until the following day, and the federal report was not filed until the resident's representative observed the bruise and contacted law enforcement. Staff interviews and policy reviews confirmed that the facility did not follow its own procedures for timely reporting and documentation of the incident.