Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the required state agency as mandated by their own policy and state guidelines. A resident with multiple complex medical conditions, including severe cognitive deficit, was found to have an unstageable pressure ulcer on the right lateral elbow, which had deteriorated and was accompanied by a skin tear. The medical record did not document when or how the skin tear occurred, and both the Registered Nurse and Director of Nursing confirmed the absence of this documentation. Despite the facility's Abuse Prohibition Policy requiring immediate reporting of injuries of unknown origin to the Administrator, Director of Nursing, and appropriate state and federal agencies, the injury was not reported. The deficiency was identified during a complaint investigation, and the lack of documentation and reporting was verified through medical record review, staff interviews, and policy review.