Failure to Timely Report Injuries of Unknown Source to State Agency
Penalty
Summary
The facility failed to timely report injuries of unknown source to the State agency for four residents with severe cognitive impairment. Each of these residents was dependent on staff for activities of daily living and had significant communication deficits, making them unable to explain the cause of their injuries. The injuries included significant bruising and, in one case, a fracture, all of which were unwitnessed and lacked a clear explanation. Despite facility policy requiring immediate or timely reporting of such incidents, these injuries were either not reported or reported late to the State agency. For one resident, a large bruise was discovered on the left lower arm, but the internal investigation did not include interviews with outpatient therapy staff or the resident's daughter, both of whom were present during therapy sessions. The Director of Nursing (DON) confirmed that the injury was not reported to the State agency and that the investigation's conclusion was not documented. Another resident was found with a bruise on the forehead, and although it was suspected to be caused by a broda chair, no interventions were implemented to prevent recurrence, and the injury was not reported to the State agency. The DON again confirmed the lack of reporting and documentation of the investigation's conclusion. A third resident was observed with a forehead bruise and was sent to the hospital for evaluation. The self-reported incident was not submitted to the State agency until two days after the injury was discovered. The fourth resident had swelling and discoloration of the left hand and wrist, later diagnosed as a fracture, with no known cause. The DON suspected the injury might have occurred due to the resident's hand getting caught in a wheelchair wheel, but this was not documented, and the injury was not reported to the State agency. In all cases, the facility's own policy defined injuries of unknown source as possible indicators of abuse and required timely reporting, which was not followed.