Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
A deficiency occurred when the facility failed to report an injury of unknown origin for a resident to the state agency as required. The resident, who had diagnoses including dementia, borderline personality disorder, and was on anticoagulant therapy, was found with multiple injuries including an abrasion to the lip, redness to the left sclera, and a lump on the back of the head. Documentation showed that the injuries were unwitnessed, and the resident was unable to explain how they occurred due to severe cognitive impairment. The facility's internal records, including care plans and incident reports, documented the injuries and the notifications made to the family, ADON, and physician, but there was no evidence that the incident was reported to the state agency as required by facility policy and regulation. Staff interviews confirmed that the expectation was for injuries of unknown origin to be reported immediately to nursing leadership and, if necessary, to outside agencies. The CNA, LPN, ADON, Social Services Manager, Executive Director, and DON all described the importance of reporting such injuries, especially when the resident cannot communicate what happened. Despite these expectations and the facility's own policies, the incident involving the resident's injuries was not reported to the state agency. The DON stated that the incident did not meet the definition of injury of unknown origin according to their policy, citing documentation that the resident was known to rest her head on the headboard and bite her lip, although this documentation was dated after the incident. A review of the facility's policies confirmed that injuries of unknown source, especially when unwitnessed and unexplained by the resident, are to be reported to the state agency. The facility's incident report log and self-report records did not show any report made for this incident. The failure to report the injury of unknown origin was identified through closed record review, staff interviews, and policy review, establishing that the facility did not follow its own procedures or regulatory requirements in this case.