Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically regarding the reporting and investigation of an injury of unknown origin for one resident. On the day of the incident, a staff member observed a significant burn on the resident's leg and sent the resident upstairs, noting that the injury could not have occurred in the patio area. The agency RN who received the resident upstairs cleaned the wound, informed the incoming nurse, and stated she notified the DON before leaving. However, the DON later reported not being notified of the injury and confirmed that no investigation or report to the State was initiated at that time. The resident in question had multiple complex medical diagnoses, including type 2 diabetes, chronic kidney disease, and heart failure, and was cognitively impaired. Documentation showed that the injury was a full-thickness burn of significant size, described as severe by the wound care doctor. The injury was first documented in a progress note as a skin tear, and a subsequent wound evaluation confirmed the extent of the burn. Despite the seriousness of the injury and the facility's policy requiring immediate reporting and investigation of injuries of unknown origin, no such actions were taken until much later. Interviews with facility staff, including the new administrator and DON, revealed a lack of awareness and follow-through regarding the required reporting and investigation procedures. The administrator acknowledged that the injury was not reported or investigated as required by policy and federal regulations. Additionally, an email from the administrator indicated no reportables for injury of unknown origin in the relevant period, further confirming the failure to report this incident. The facility's own policy mandates immediate reporting of such events to the State and other authorities, which was not followed in this case.