Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of injury of unknown origin for a resident with dementia, hypertension, arthritis, and a history of kidney stones. The resident, who required full assistance with daily activities and had severely impaired cognitive skills, was found by a nurse aide to have six open, red, and bloody skin tears on her inner right forearm. The nurse aide notified a nurse, who evaluated and dressed the wounds, but there was no evidence that the incident was reported to local law enforcement or Adult Protective Services (APS) as required. Additionally, the facility did not submit an Investigation Report to the State Agency within the required five-day timeframe. Staff interviews and record reviews revealed that the Director of Nursing, Social Worker, and current Administrator were unaware of the incident, as they were recently hired and the staff involved were no longer employed at the facility. The facility was unable to provide documentation of the required notifications or the investigation report, and attempts to contact the responsible party and involved staff were unsuccessful. The lack of timely reporting and documentation constituted a failure to follow mandated procedures for suspected abuse, neglect, or injury of unknown origin.