Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the Ohio Department of Health (ODH) as required by policy. A resident with diagnoses including severe protein calorie malnutrition, altered mental status, COPD, and weakness was readmitted to the facility after a hospital stay, with no documented skin concerns upon return. Several weeks later, during wound rounds, the Assistant Director of Nursing (ADON) discovered a new skin tear on the resident's lower back, measuring 7.0 cm by 15.0 cm by 0.1 cm, with scant drainage. There was no documentation in the medical record regarding how or when the skin tear occurred. Interviews with the ADON, the Administrator, and the Regional Director of Clinical Services confirmed that the injury was new, of unknown origin, and that no investigation was conducted to determine its cause. Additionally, no Serious Reportable Incident (SRI) was completed or submitted to ODH for this injury, despite facility policy requiring notification of all injuries of unknown source within 24 hours. Review of the ODH Certification and Licensure System confirmed the absence of a report for this incident.