Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident to the State Agency, as required by policy and regulation. The resident, who was cognitively impaired and required substantial assistance with activities of daily living, was observed with a dark, faded area on her left cheek. Staff interviews and record reviews revealed that the origin of the injury was unknown, and the resident had accused staff of hitting her. The unit manager observed the injury, reported it to the wound care team, and documented the area as a skin tear, but no investigation was initiated to determine the cause of the injury. Despite the facility's policy requiring immediate reporting and investigation of injuries of unknown origin, the incident was not reported to the State Agency, and no investigation was conducted. The administrator confirmed that the information was not forwarded to them until after the surveyor's inquiry, and acknowledged that the incident should have been reported and investigated. The facility's failure to follow its own policy resulted in the injury going unreported and uninvestigated.