Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or injuries of unknown source were reported to the New York State Department of Health within the required timeframe. Specifically, a resident with a history of coronary artery disease, diabetes mellitus, and non-Alzheimer's dementia, who was moderately cognitively impaired and dependent on staff for most activities of daily living, experienced an unwitnessed fall from bed. The incident resulted in a hematoma and swelling around the left eye, and the resident was unable to explain how the fall occurred. The event was documented by both nursing and physician staff, and the resident was transferred to the hospital for further evaluation. Despite the facility's policy requiring immediate reporting of such incidents, the event was not reported to the Department of Health. Interviews with the DON and the Administrator revealed that the incident was not reported because there was no suspicion of abuse and the resident was sent to the hospital. The facility's failure to report the unwitnessed fall with injury, as required by federal and state regulations and the facility's own policy, constituted the deficiency identified during the survey.