Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state surveying agency as required by policy. Medical record review showed that a resident with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension, who was dependent on staff for all activities of daily living, was found with a hematoma and a small amount of blood on her pillow during morning care. The source of the injury was not observed, and the resident was unable to explain what happened. The incident was documented in the facility's incident log, and staff reported the findings to nursing. Despite the facility's policy requiring immediate reporting of all injuries of unknown source to the Administrator or designee and notification of the state agency within two hours if serious bodily injury is identified, the Director of Nursing confirmed that the incident was not reported to the State Surveying Agency. The failure to report was identified through medical record review, incident log review, staff interview, and policy review, and affected one resident out of five reviewed during the survey.