Failure to Report Injury of Unknown Origin and Notify Family
Penalty
Summary
The provider failed to follow its policy for reporting injuries of unknown origin to the South Dakota Department of Health (SD DOH) and to the resident's representative. During a family visit, a resident was found to have significant bruising and swelling on her left hand and forearm, which was not present during a previous visit. The family was not notified of the injury, and digital photographs taken by the family documented the extent of the bruising. Review of the resident's electronic medical record and interviews with staff confirmed that the injury was first documented in a medical provider's note, which stated that no definitive cause for the injury was found. The injury was not related to a recent lab draw, as that procedure was performed on the resident's right arm. Staff interviews revealed that it was the responsibility of the LPN to notify the resident's family and a nurse supervisor or administrator about the injury, especially since the cause was unknown. However, this notification did not occur, and the injury was not reported to the SD DOH as required by the facility's abuse and neglect policy. The policy specifically mandates notification of designated agencies and the resident's family in cases of suspected abuse, neglect, or injury of unknown origin, and that such notifications be documented. The administrator confirmed that these procedures were not followed in this instance.