Failure to Notify Physician and Family of New Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately notify a resident's physician and representative when a significant change in the resident's physical status was discovered. Specifically, a resident with severe cognitive impairment and multiple complex diagnoses, including Alzheimer's disease, dementia, and a history of falls, was found to have an injury of unknown origin on her face at the time of discharge. The injury, described as a linear abrasion with open skin and signs of blunt force trauma, was not present earlier in the day and was not reported to the physician or family as a new injury. Staff interviews and record reviews revealed that the injury was discovered by a family member at discharge, who then raised concerns about the resident's care. Facility staff, including the DON and RN, assumed the injury was related to a previous, witnessed fall that had occurred several days earlier and had already been reported. As a result, the new injury was not recognized as a separate incident, and no immediate notification or medical intervention was provided. The physician confirmed that she was not notified of the new wound and stated that it should have been treated and reported as a new injury of unknown origin. Documentation showed inconsistencies in staff observations, with some staff noting only a bruise and others unaware of the open wound. The facility also failed to report the injury of unknown origin to the state agency within the required timeframe. The lack of immediate recognition and notification of the new injury led to a delay in appropriate medical assessment and intervention for the resident.