Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an allegation of injury of unknown origin was reported immediately to the Administrator or their designated representative, and subsequently to the state agency within the required 2-hour timeframe. According to the facility's abuse prevention and prohibition policy, any employee or agent who becomes aware of abuse, neglect, injuries of unknown origin, or alleged misappropriation of resident property must immediately report the matter to the Administrator. In this case, a resident was found with a hematoma and bruising on the right side of the head. The injury was discovered by a CNA and reported to an LPN on the morning of the incident, but the LPN did not notify administrative staff until later in the day, after lunch. The LPN confirmed during an interview that the injury was not reported immediately as required. Further review and interviews revealed that the administrative staff, including the ADON, DON, and Administrator, were not made aware of the injury until the evening of the same day. The critical incident report was entered nearly two hours after the injury was discovered, and the state agency was not notified within the mandated 2-hour window. The facility's own staff confirmed that the reporting procedures outlined in their policy were not followed, resulting in a delay in both internal and external notification of the incident involving the resident with the head injury.