Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an Injury of Unknown Origin for one resident who was severely cognitively impaired and required significant assistance with daily activities. The resident, who had multiple medical diagnoses including dementia, diabetes, and heart failure, was found to have a large, dark purple bruise on the left lower abdomen. The bruise was first observed by a CNA during the early morning hours and was immediately reported to an LPN, who then informed the Director of Nursing (DON). The DON was notified of the injury the same morning, and the administrator was also informed. Despite the immediate internal reporting, the facility did not submit the required initial report to the State Agency until four days after the injury was discovered. The facility's policy requires that such incidents, especially those classified as Injuries of Unknown Origin, be reported to the State Agency immediately after assessment. Interviews with staff and review of records confirmed that the injury met the criteria for immediate reporting, but this was not done in accordance with policy.