Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown origin for one resident with severe cognitive impairment and a history of behavioral symptoms. The resident, who had diagnoses including Alzheimer's disease, depression, and anxiety, was assessed as being at risk for abuse, neglect, and misappropriation. On the date of the incident, a CNA notified a nurse that the resident had new bruises on multiple areas including the lower extremities, chest, abdomen, hip, and coccyx, as well as swelling on the abdomen. The resident was unable to explain the bruising, and staff were unaware of its cause. According to facility policy and state regulations, any suspicion of abuse, neglect, or injury of unknown origin must be reported immediately, defined as within two hours, to the administrator and appropriate authorities. However, the injury was discovered at 11:36 AM and was not reported to the State Survey Agency until almost six hours later. The DON confirmed that the injury should have been reported within the two-hour window, but was not notified immediately. This delay in reporting was not in accordance with the facility's policy and regulatory requirements.