Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) within the required two-hour timeframe after it was first identified. On 8/17/25, staff observed a resident with discoloration and minor swelling to the left clavicle during care, but no immediate investigation was initiated, and the NJDOH was not notified. The injury was later diagnosed as a closed, displaced fracture on 8/19/25. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were not informed of the injury at the time it was discovered, and the LPN/S who identified the injury did not escalate the issue as required by facility policy. The delay in reporting and investigation resulted in the facility not ruling out possible abuse in a timely manner. The ADON acknowledged that staff providing direct care should have been placed off duty pending investigation and that notifications to the NJDOH and Ombudsman should have occurred immediately or within the required timeframe. Facility policy mandates immediate reporting of any injury of unknown origin, but this protocol was not followed, leading to a late submission of the Facility Reported Event (FRE) and delayed initiation of the investigation.