Failure to Timely Report and Document Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that injuries of unknown origin were reported immediately, but not later than two hours after the allegation was made, for two of nine sampled residents reviewed for abuse. Facility policy required that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported promptly to appropriate authorities, including the State licensing agency, Ombudsman, resident representative, law enforcement, and the attending physician. The policy also required a written report of the findings of the investigation within five working days. However, for the residents in question, the facility did not complete occurrence reports, head-to-toe assessments, or document how the injuries occurred. There was also a lack of detailed descriptions of the injuries in the medical records. One resident, with diagnoses including Paranoid Schizophrenia, Alzheimer's Disease, and Hypertension, and who was moderately cognitively impaired, sustained multiple injuries of unknown origin on several occasions, including knots on the head, a painful swollen hand, a large bruise on the neck, and an open area on the abdomen. None of these incidents were properly documented or reported as required. The resident was later transferred to the emergency department, where life-threatening injuries were diagnosed, including a fractured sternum, multiple rib and lumbar vertebrae fractures, a cervical artery dissection, a lacerated spleen, and a subdural hematoma. The facility did not report these injuries to the State Agencies. Another resident, with severe cognitive impairment and total dependence on staff, sustained red scratches to the face, bruising to the head, and a swollen hand with a fractured finger. The facility again failed to complete an occurrence report, a head-to-toe assessment, or document how the injury occurred. The physician was not notified of the injuries, and there was no detailed description in the medical record. Interviews with the DON and Administrator confirmed that the injuries were not reported to the State Agencies and that documentation and reporting were insufficient.