Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy by not reporting an injury of unknown origin for a resident who was dependent on staff for all Activities of Daily Living (ADLs) and unable to communicate verbally. The resident, who had a history of epilepsy, cerebral palsy, pressure ulcers, falls, and required full staff assistance, was found by a family member to have a black eye and bruising around the left eye. The family member reported the injury to staff, but the administrator stated that staff had witnessed the resident hitting her head on a table, attributing the injury to self-harm. However, the family member disputed this, stating the resident did not exhibit such behaviors. The resident's assessment indicated no documented mood or behavioral issues and a high level of cognitive impairment, making self-reporting impossible. Further investigation revealed inconsistencies in staff accounts. The activity aide who was believed to have witnessed the incident was unsure if the resident had actually hit her head and did not report the incident immediately. The nurse on duty did not document the event or complete the required risk management process, which was only finalized by the DON nearly two weeks later. Multiple staff interviewed could not confirm witnessing the injury or explain its origin. The facility's abuse prevention policy required reporting injuries of unknown source, especially when the source was not observed and the injury was suspicious. Despite this, the injury was not reported to the state agency as required, and internal documentation was incomplete.