Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
Facility staff failed to ensure the timely reporting of an injury of unknown origin for one resident with severe cognitive impairment and total dependence for activities of daily living. The resident, who had multiple complex diagnoses including dementia, malnutrition, and physical debility, was found by an RN to have a black and blue area on the chest. The nurse documented the finding and intended to notify the nurse practitioner, but there was no evidence that the injury was reported to the physician, resident representative, or appropriate state agencies within the required timeframes. Interviews with facility staff, including the Administrator, CNA, LPN, and ADON, revealed that the facility's policy requires immediate reporting and investigation of unexplained injuries, as well as notification of the physician and resident representative. However, the Administrator confirmed that no Facility Reported Incident (FRI) was submitted for this injury, and the ADON was unable to find documentation of timely notifications or an investigation related to the incident. Staff interviews further confirmed that such injuries, especially in nonverbal residents, should be treated as potential abuse or neglect and reported accordingly. A review of facility policies on unexplained injuries and abuse indicated clear procedures for reporting, investigating, and notifying appropriate parties within specified timeframes. Despite these policies, the required steps were not followed in this case, as there was no documentation of immediate notification or investigation of the injury of unknown origin. The deficiency was confirmed during the survey, and no additional information was provided by the facility at the end of the review.