Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to notify the New Jersey Department of Health (NJDOH) and the Office of the Ombudsman immediately or within two hours after identifying an injury of unknown origin, as required by federal and state regulations and the facility's own abuse policy. The incident involved a resident with severe cognitive impairment, multiple diagnoses including dementia, and who was receiving hospice services. The resident was found with a laceration on the inner left lower leg during morning rounds, which was not observed or reported by staff during the previous shifts, despite documentation indicating that ace wraps were to be applied and removed on a regular schedule. Upon investigation, it was determined that the injury occurred when the resident, who had recently received a new wheelchair with leg rests, made contact with a bolt on the footrest while habitually standing up and moving away from a table. Blood and tissue were found on the wheelchair footrest, supporting this conclusion. Staff interviews revealed that the injury was not noticed or reported by those responsible for the resident's care during the night and evening shifts, and there was uncertainty about whether required care tasks, such as donning and doffing ace wraps, were actually performed as documented. Despite the clear requirement to report injuries of unknown origin immediately or within two hours, the facility did not notify the NJDOH and Ombudsman until 21 days after the incident, and only after being prompted by a surveyor during an onsite complaint investigation. Both the DON and the Administrator acknowledged that the injury should have been reported immediately, regardless of the subsequent determination of its cause. The facility's policy and state regulations require prompt reporting to ensure proper oversight and investigation of potential abuse, neglect, or mistreatment.