Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the California Department of Public Health (CDPH), the ombudsman, and local law enforcement as required. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including metabolic encephalopathy and depression, who was found to have discoloration on the right side of the forehead. The injury was first observed by a CNA and reported to an LVN, who acknowledged not knowing the cause and could not recall if the Director of Nursing (DON) or Administrator (ADM) were informed at the time. Interviews with staff confirmed that the discoloration was considered an injury of unknown origin and should have triggered immediate notification to facility leadership and external agencies. Both the LVN and RN interviewed stated that such injuries must be reported to the DON and ADM, who are then responsible for notifying the appropriate authorities and initiating an investigation. The DON confirmed that reporting injuries of unknown origin is essential for resident safety and that the incident was not reported because the possibility of abuse was not considered at the time. The ADM stated that injuries of unknown origin are to be reported to CDPH, the ombudsman, and the police, but did not recall being informed of the incident when it occurred. Upon seeing the resident several days later and not observing any discoloration, the ADM did not report the incident. Review of the facility's policy confirmed the requirement for immediate reporting of all alleged violations involving abuse, neglect, or injuries of unknown source to multiple agencies and individuals.