Failure to Timely Investigate and Report Injury of Unknown Source
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 to the State Survey Agency as required. Specifically, an incident involving an unwitnessed fall resulted in a resident sustaining a hematoma to the forehead and a skin tear to the eyebrow. The incident was not investigated or reported within the required 2-hour or 24-hour timeframes for reporting and investigating abuse and neglect, as outlined in both federal regulations and the facility's own abuse prohibition policy. The resident involved was an elderly female with multiple diagnoses, including hypertension, diabetes, malnutrition, schizophrenia, anxiety disorder, depression, muscle weakness, and dysphagia. She was cognitively impaired, requiring varying levels of assistance with daily activities and was always incontinent. On the day of the incident, the resident was found on the floor by an LPN, bleeding from a head injury. The nurse provided immediate care, notified the physician and DON, called 911, and the resident was transported to the hospital. The resident returned the same day with no further acute findings. Despite the facility's policy requiring prompt investigation and reporting of such incidents, the administrator acknowledged that the incident was neither investigated nor reported to the state agency within the required timeframe. Interviews with the administrator and DON confirmed that the process for reporting was not followed, and the administrator accepted responsibility for the oversight. The facility's policy clearly outlines the need for timely investigation and reporting, which was not adhered to in this case.