Failure to Timely Report Injuries of Unknown Origin and Notify Authorities
Penalty
Summary
The facility failed to report an alleged violation to the state agency regarding injuries of unknown origin for one resident with advanced Alzheimer’s dementia, severe cognitive impairment, and who was nonverbal and bed/chair bound. The resident was observed with yellow bruising on the sternal chest wall and dark red-purple bruising on the right rib cage, which were not consistent with the care provided. These injuries were not reported to the hospice provider or the resident’s legal representative. Staff interviews revealed that the bruising was noticed by both a registered nurse and a certified nurse assistant, but there was confusion and lack of follow-up regarding who should report the incident. The facility’s policy required immediate reporting of such incidents to supervisors and the administrator, as well as prompt notification of the attending physician and legal representative, but these steps were not followed. Further review showed that the abuse coordinator documented a change in condition, attributing the rib bruising to a two-person transfer without confirming the details or notifying the family. There was no documentation explaining the cause of the sternal bruising or evidence that the family was informed at the time of the incident. The nursing home administrator, who also served as the abuse coordinator, confirmed that the injuries would have been formally investigated and reported to the state agency if they had been aware, but the issue only came to their attention during the survey.