Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to complete a thorough investigation and timely reporting of an injury of unknown origin for a resident with severe cognitive impairment and a history of combative behavior. The resident, who had diagnoses including dementia and cerebral infarction, was found with swelling and discoloration to the right hand, which later was confirmed as a fracture. Staff noted the resident was unable to state what happened, and documentation indicated the resident had been physically aggressive with staff during care prior to the injury. Despite the injury being of unknown origin, the facility did not report the incident to the New Jersey Department of Health as required. The DON stated that the injury was not considered of unknown origin because the resident was known to be combative, and it was assumed the injury occurred during care. The investigation did not include checking other residents for injuries to rule out abuse, and staff statements were collected only after management returned following the weekend, focusing on general encounters rather than the specific incident. Facility policy required immediate investigation and reporting of suspected abuse, neglect, or injuries of unknown source, including notification to state agencies and other relevant parties. However, the investigation did not fully adhere to these procedures, as it did not thoroughly rule out abuse or neglect, nor did it ensure timely and complete reporting to the appropriate authorities.