Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or injuries of unknown origin were reported to the New York State Department of Health as required by federal and state law. For two residents with severe cognitive impairment and significant medical histories, incidents involving unexplained injuries were not reported. One resident, with diagnoses including Alzheimer's Disease, Insomnia, Diabetes, and Spontaneous Ecchymoses, was found with multiple scratches and large ecchymoses on various parts of the body. Despite the inability of the resident to provide a history and no witnesses to the incident, the facility concluded, after reviewing surveillance and clinical baseline, that the injuries were not of unknown origin and did not report the incident. Another resident, also with severe cognitive impairment and a diagnosis of osteoporosis, was found with skin discoloration, swelling, and later diagnosed with a fracture of the humeral head and neck. The resident was nonverbal and unable to explain the injury, and there were no witnesses or clear cause identified. The facility's investigation determined the injury was consistent with the resident's medical condition and therefore did not report it as an injury of unknown origin. In both cases, the facility's policy required reporting of injuries of unknown source, but the incidents were not reported to the state authorities. Staff interviews confirmed that the decision not to report was based on the facility's interpretation of the residents' clinical baselines and diagnoses, rather than the absence of a known cause for the injuries.