Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to report an injury of unknown origin to the Ohio Department of Health (ODH) as required. A resident with multiple diagnoses, including discitis, osteomyelitis, hypertensive heart disease with heart failure, type II diabetes mellitus, and chronic diastolic heart failure, was found to have a large, raised bruising lesion on the left lower leg. The lesion measured 11 cm by 7 cm, was mottled with shades of purple, black, and pinkish, had irregular borders, was swollen, warm to the touch, and surrounded by erythematous and swollen skin. The resident, who had mild cognitive deficits and was dependent on staff for most activities of daily living, could not recall how or when the injury occurred, and no trauma was reported. The physician was notified, and the resident was sent to the emergency room for evaluation. Despite the facility's policy requiring immediate investigation and reporting of injuries of unknown origin or suspicious injuries, the incident was not reported to ODH. The Director of Nursing confirmed that the injury was not reported as required. The facility's policy also mandates staff education on identifying signs and symptoms of abuse and monitoring residents for suspicious or unexplained bruising, but this protocol was not followed in this case, resulting in non-compliance.