Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident who was found with a significant bruise covering almost the entire left eyelid. The incident was first brought to staff attention by the resident's daughter, who noticed the bruise and believed it may have been caused by the resident resting his face against a hoyer sling during transfers. Nursing staff documented the bruise, noting its size and location, and that the resident was cognitively intact, denied pain, and could not recall how the injury occurred. Multiple staff members and the resident's representative provided differing accounts regarding the possible cause, including difficulty with glasses and the use of the hoyer lift, but no definitive cause was established. Despite the facility's policy requiring the reporting of all injuries of unknown source to the State survey agency, the incident was not reported. The policy specifically lists physical injury of unknown source as a possible indicator of abuse and mandates reporting within specified timeframes. Interviews with facility leadership revealed that the Nursing Home Administrator did not consider the injury to be of unknown origin, citing the resident's use of glasses as a likely explanation, and did not complete the required injury of unknown source flowchart to document the decision-making process. Surveyor review confirmed that the injury was not observed by staff, the resident could not recall the cause, and the location of the bruise was not generally vulnerable to trauma. The facility did not provide additional documentation or policies to justify the decision not to report. The lack of reporting was based on subjective judgment rather than adherence to the facility's written policy and regulatory requirements.