Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency as required by its Abuse Policy and Procedure. A resident with multiple diagnoses, including mental health issues, dementia, and cognitive impairments, reported to staff that they had injured their finger, stating it was due to a fall. However, the resident was unable to specify where or when the fall occurred, and staff noted that the resident was not a reliable historian and could have sustained the injury in various ways. Documentation in the clinical record and interviews with staff confirmed the resident's cognitive limitations and behavioral issues, which contributed to uncertainty about the cause of the injury. Despite the facility's policy requiring immediate reporting of suspected abuse, neglect, exploitation, misappropriation, or injury of unknown origin to the Administrator and State Agency, the incident was not reported. Both the Administrator and Assistant Director of Nursing acknowledged that the resident's recall was unreliable and that the injury was of unknown origin, confirming that it should have been reported according to policy and state law.