Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of injury of unknown origin for one resident, as required by both facility policy and regulatory guidelines. A resident was noted to have increased confusion and lethargy, leading to a transfer to the emergency department. Later, the resident's family informed facility staff that a CT scan at the hospital revealed internal bleeding in the head, which the hospital indicated could be from a possible unwitnessed fall. Nursing staff reviewed records and found no documented falls or incidents in the prior 24 hours. The nurse on duty notified the Director of Nursing (DON) about the new information from the family, but no written investigation or incident report was completed, and the event was not reported to the state agency. The facility's policies require that all accidents and incidents, including injuries of unknown origin, be reported to the department supervisor, documented with an incident report, and reported to the abuse coordinator and state agency. Despite these requirements, the DON confirmed that no investigation or report was made because the source of the injury was unknown and there were no documented falls. The administrator, who serves as the abuse coordinator, was not informed of the injury until after reviewing the nursing note and acknowledged that the incident should have been identified and investigated as an injury of unknown origin.