Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately as required. Specifically, staff did not submit a report to the State Survey Agency regarding a resident who was found on the floor with a deep 10 cm laceration to the top of his head, which required hospitalization and 15 staples. The injury was unwitnessed, and the source could not be explained by the resident, who had a history of dementia and repeated falls. Despite the severity and unexplained nature of the injury, the incident was not reported through the required channels. The resident involved was an elderly male with diagnoses including heart failure, dementia, depression, abnormal gait, and a history of falls. On the day of the incident, staff heard a loud thump and found the resident on his back with a significant head laceration and uncontrolled bleeding. The resident was unable to explain what happened, and staff could not identify any object or surface in the room that could have caused the injury. The facility's investigation included interviews, room inspection, and review of the resident's care plan and medical records, but the cause of the injury remained undetermined. Interviews with facility staff, including the administrator and DON, revealed that the injury met the criteria for an injury of unknown source, as it was unwitnessed, unexplained by the resident, and suspicious due to its extent. However, the administrator did not report the incident, believing it was not suspicious after internal review. This decision was made despite the facility's policy and state guidance requiring immediate reporting of such injuries. The failure to report the incident as required constituted a deficiency in the facility's abuse, neglect, and incident reporting procedures.