Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the Administrator/Abuse Coordinator within the required timeframe for a resident who was reviewed for abuse. The incident involved a resident with dementia and physical impairments who was found to have significant bruising on her arm, breast, and back. Multiple certified nursing assistants (CNAs) observed the bruising at different times, with one CNA noticing the bruises as early as two days before the injury was reported to the Administrator. Despite the facility's policy requiring immediate reporting of such injuries, the bruising was not promptly communicated to the appropriate authorities. The resident was dependent on staff for most activities of daily living and had a history of chronic fractures. On the day of the incident, a CNA discovered extensive bruising while assisting the resident with care and reported it to the assigned nurse. The nurse did not immediately assess the resident in person and did not report the injury to the Administrator until several hours later. Other staff members also observed the resident's change in condition and the presence of bruising but did not escalate the concern as required by facility policy. Interviews with staff revealed a lack of clarity and adherence to the facility's protocol for reporting injuries of unknown origin. Some CNAs admitted to not reporting the bruising when first observed, assuming others were aware or that it was not necessary. The facility's policy clearly states that any unexplained injury, especially those of significant extent or in unusual locations, must be reported immediately to the Administrator. The delay in reporting and failure to follow established procedures resulted in a deficiency related to timely reporting of suspected abuse, neglect, or injury.