Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency within the required timeframe for one resident. The resident, who had a history of stroke, right-sided paralysis, moderate cognitive impairment, and was on anticoagulant and antiplatelet medications, was found with extensive bruising and swelling on her right arm, extending from the armpit to the hand. The injury was first noted by staff in the early morning, and the resident was unable to recall any incident that could have caused the injury. Documentation showed that the injury was reported to the on-call nurse, but not to the facility administrator or the State Agency until the following day, exceeding the mandated reporting window. Staff interviews revealed confusion regarding the reporting protocol, with some staff believing the State Agency should be notified within 24 hours, while the facility's policy required immediate reporting, but not later than two hours, if the injury involved suspected abuse or resulted in serious bodily injury. The administrator confirmed she was not informed until the next morning and subsequently filed the report with the State Agency. The facility's own Abuse Prevention Plan defined injuries of unknown source and outlined the required reporting timelines, which were not followed in this case.