Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately as required by regulation. Specifically, an injury of unknown origin was discovered on a female resident who was receiving respite care and had multiple diagnoses, including Alzheimer's disease, dementia, Parkinson's disease, and a history of falls. The injury, a linear abrasion with clotted, bright red skin on the right cheek, was observed by the family at the time of discharge, but was not reported to the state agency within the required 24-hour timeframe. Staff interviews and record reviews revealed that the resident had a witnessed fall several days prior to the discovery of the injury, but at the time of the fall, no injuries were noted. Multiple staff members, including the DON, wound care nurse, and RN, stated that they had seen only a light bruise on the resident's face prior to discharge and were unaware of any open wound or new injury. The DON and other staff assumed that the family's concern was related to the earlier fall and its resulting bruise, not recognizing that a new injury had occurred. The physician and wound care nurse confirmed that the wound seen in the family’s video and photograph was not present during their last assessments and that it appeared to be a recent, open wound. The facility's policy requires that all injuries of unknown origin be reported to the administrator and, if reportable, to the state agency within 24 hours. However, the injury discovered at discharge was not reported as required. The failure to recognize and report the new injury was due to staff assuming it was related to the previous fall, leading to inaccurate communication with the family and a lack of timely notification to the appropriate authorities.