Failure to Report Injury of Unknown Origin and Update Care Plan
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey State Department of Health (NJDOH) and did not fully implement its policy for accidents and incidents by neglecting to thoroughly update the care plan after the event. A resident with severe cognitive impairment and dependent functional status was observed with unilateral bruising on the right eye and right arm. The incident was documented in the medical record, and witness statements were collected, but the event was not reported to the state as required. The Assistant Director of Nursing (ADON) confirmed that no reportable event was filed with the NJDOH, despite the facility investigating the bruises as being of unknown origin. The facility's investigation attributed the bruising to the resident's use of aspirin and underlying dementia, but did not establish a definitive root cause. Additionally, the care plan was not updated to include interventions related to the use of anticoagulants, the new bruising, or the resident's dementia diagnosis. The interdisciplinary team met to discuss the incident, but the care plan lacked specific focus and interventions addressing the identified issues. The facility's own policies required individualized interventions and reporting of such incidents, which were not followed in this case.