Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the administrator for one resident who was severely cognitively impaired and dependent on staff for all activities of daily living. The resident, who had multiple complex medical diagnoses including a stage 4 pressure ulcer, dementia, and a vertebral fracture, developed skin tears on her left upper arm and left hand during her stay. Family members reported that the resident stated a CNA was rough with her during a shower, which may have caused one of the skin tears. The skin tear was observed uncovered for several days before being dressed, and this was the third such injury since the resident's admission. Staff interviews revealed that the CNA and nurse on duty were either unaware of the injury or did not know its cause, and no incident report was completed at the time the injury was discovered. Further review showed that the facility had no documentation of the skin tear and only initiated an investigation after the surveyor requested it. The facility's policy requires that injuries of unknown source be reported to the administrator, documented, and investigated, with notification to the Department of Public Health. However, the initial report of the injury was not made until prompted by the surveyor, indicating a failure to follow established procedures for reporting and investigating injuries of unknown origin.