Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to implement its policy and procedure for timely reporting of a reasonable suspicion of a crime related to an injury of unknown source for one resident. A resident with severely impaired cognition and total dependence on staff for mobility was found with a coin-sized skin discoloration to the right eyebrow region. The discoloration was first observed by a CNA and assessed by an LVN, who could not determine the cause. The resident was unable to communicate how the injury occurred, and there were no witnesses. The facility's policy required immediate reporting of suspected abuse, neglect, exploitation, or injury of unknown source to the administrator and appropriate authorities, with 'immediate' defined as within two hours for serious bodily injury or within 24 hours otherwise. Despite these requirements, the facility did not report the injury to the California Department of Public Health (CDPH), Licensing & Certification Program, Long-Term Care Ombudsman, and local law enforcement until prompted by a family member who visited the resident and requested an investigation. The administrator acknowledged that the injury was of unknown origin and should have been reported, but delayed reporting, considering it a 'gray area' due to the resident's history of being prone to accidents. The delay in reporting was confirmed through interviews with staff and review of documentation.