Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of potential abuse, specifically injuries of unknown source, to the State Agency for one resident. The resident, who had severe cognitive impairment, muscle weakness, osteoarthritis, thrombocytopenia, dementia, and protein-calorie malnutrition, was observed to have bruising and open areas on both upper extremities. Certified Nursing Assistants reported these injuries to a nurse during care, and the Unit Manager confirmed that such injuries of unknown origin must be reported and investigated. Despite these observations and internal reports, a review of the Health Care Facility Report System showed that the facility did not report the incident to the state agency as required by policy. The Director of Nurses acknowledged the need for investigation and reporting but admitted that the incident had not yet been reported. The Administrator also confirmed that all injuries of unknown origin should be reported and investigated, but as of the time of the survey, the report to the state agency was still pending.