Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency for one resident who was severely cognitively impaired and unable to explain the cause of their injuries. The resident, who had diagnoses including epilepsy, diabetes, recurrent falls, and paranoid schizophrenia, was found with facial bruising and swelling by a family member during a visit. The clinical record indicated that the injury was first documented by a physician, with no prior notes describing the resident's facial condition or when the injury was discovered. The incident/accident report described the family member finding blood and bruising, and the resident was unable to provide an explanation due to their cognitive status. Staff statements indicated that the injury was not witnessed, and the resident later claimed to have punched themselves, but this was reported three days after the injury was observed. The resident's legal guardian expressed doubt that the resident could have self-inflicted the injuries and suggested a possible fall, but no one could confirm the cause. Despite the facility's policy requiring immediate reporting of injuries of unknown source to the State Agency, the injury was not reported as such. The Administrator and staff did not consider the incident to be of unknown origin, relying on the resident's delayed and questionable statement of self-harm, despite the resident's severe cognitive impairment and inability to reliably communicate. The facility's failure to report the injury as required by policy and regulation constituted the deficiency identified by surveyors.