Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident as required by its own policy and federal and state law. The policy mandates that all injuries of unknown origin, defined as injuries where the source is not observed or cannot be explained by the resident and are suspicious due to their extent or location, must be immediately reported to the Facility Administrator and appropriate agencies. In this case, a resident with severe cognitive impairment and multiple medical diagnoses, including subdural hematoma and Down's Syndrome, was found with scratch marks on the forehead and purplish discoloration and swelling around the left eye. The resident was unable to explain the cause of the injuries, and staff interviews confirmed that the injuries were not present the previous day. Despite the facility's policy and the nature of the injuries, there was no evidence that the injury of unknown origin was reported to state and local agencies as required. The former DON acknowledged that the injury was initially considered of unknown origin until the investigation concluded. Staff documentation and interviews confirmed the injuries were first observed during morning care, and the resident was non-verbal and unable to communicate about the incident. The Administrator confirmed that such injuries should be reported, but the required reporting did not occur.