Failure to Immediately Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an allegation of abuse or injury of unknown origin to the Administrator or Abuse Prevention Coordinator as required by facility policy. According to the policy, all incidents and allegations of abuse, including injuries of unknown origin, must be reported immediately to the administrator or designee. In this case, a nurse aide observed multiple bruises on a resident's left arm, breast, and axilla during the evening shift, and an LPN documented the injuries as being of unknown cause or onset. Facility documentation indicated that the injury was identified by the LPN, but there was no evidence that the Administrator was notified within two hours as required. The resident involved had diagnoses including dementia and ventricular tachycardia, was cognitively impaired, and required staff assistance for personal hygiene and transfers. Despite the identification and documentation of the injuries, the Administrator was not notified until nearly two days later, and an investigation was not initiated until that time. Interviews with the Administrator confirmed that staff did not follow the facility's policy for immediate notification regarding the injury of unknown origin.