Failure to Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin to the Administrator/Abuse Coordinator for a resident with severe cognitive impairment and wandering behaviors. The resident, who had diagnoses including metabolic encephalopathy, dementia with behavioral disturbance, and Alzheimer's disease, was observed wandering into other residents' rooms, attempting to get into their beds, and was unable to provide clear explanations for her actions or injuries. On two separate occasions, the resident was found with unexplained bruises: one on the back of her right leg and another on her left eyebrow. In both cases, the source of the injuries was not witnessed, and the resident could not describe what had happened. A review of the clinical record and incident reports revealed that while the injuries were documented by staff, there was no associated investigation conducted or provided for either incident. The facility's policy required that injuries of unknown origin be immediately investigated and reported to the Administrator and, if necessary, to the State Agency. However, the Administrator confirmed that these incidents were not reported to him, and no further investigation was initiated as required by facility policy. Interviews with the Administrator/Abuse Coordinator confirmed that the protocol was not followed, as injuries of unknown origin should have been reported to initiate an investigation and determine if further reporting to the State Agency was necessary. The lack of reporting and investigation for these injuries constituted a failure to comply with the facility's own policy and regulatory requirements regarding the timely reporting and investigation of suspected abuse, neglect, or injuries of unknown origin.