Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an injury of unknown origin involving a resident was reported to the Administrator and the State Survey Agency within the required timeframe. According to facility policy, all incidents, accidents, and injuries of unknown source must be reported immediately, or no later than two hours after discovery, to the appropriate authorities. In this case, a resident with diagnoses including dementia, hypertension, and peripheral vascular disease was found to have discoloration and bruising below the right eye, which was first documented by a registered nurse as purpura. The resident was cognitively severely impaired and unable to recall how the injury occurred. Despite multiple staff members, including registered nurses, nurse practitioners, and the medical director, being aware of the injury over several days, the incident was not reported to the Director of Nursing, Administrator, or the New York State Department of Health within the mandated timeframe. Progress notes and staff statements indicated that the injury was observed, discussed among staff, and assessed by medical personnel, but the required notifications and reporting were not completed as per facility policy and state regulations. The facility's own documentation and staff interviews confirmed that the injury was of unknown origin and should have triggered immediate reporting. Interviews with facility staff, including the DON, Administrator, and Medical Director, revealed a consensus that the initial nurse who identified the injury should have reported it for further assessment and to the appropriate authorities. The failure to report the injury of unknown origin in a timely manner constituted a violation of both facility policy and state regulations, as all agreed that the incident met the criteria for mandatory reporting within 24 hours.