Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the appropriate State agency within the required state-mandated timelines for one resident. The resident, who had severe cognitive impairment, was completely dependent for transfers and required a two-person assist with a Hoyer sling. The resident was admitted with diagnoses including acute post-hemorrhagic anemia and dysphagia. On a specific date, a nurse observed that the resident's left breast was swollen to three times the size of the right, was engorged, hard to palpate, and had a firm lump, along with bruising on the left side of the abdomen. The nurse was informed that the resident had screamed during a transfer with a sit-to-stand device, and the incident was reported to the evening shift nurse. The nurse who discovered the injury communicated the findings to the facility's administrator and director of nursing, believing the injury should be reported. Despite this, no Facility Reported Incident (FRI) was submitted to the State Survey Agency regarding the injury. Public complaints were later received by the State Survey Agency, indicating that the resident had significant bruising and swelling and was not sent to the hospital for several days after the injuries became apparent. Upon review, facility leadership confirmed that the injury of unknown origin was not reported as required.