Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident with severe cognitive impairment and Alzheimer's disease. A Certified Nursing Assistant (CNA) discovered a discoloration on the resident's left lower jaw while providing care and reported it to the charge nurse. The Change of Condition form documented the injury, and both the Administrator and Director of Nursing (DON) were notified. Despite this, the injury was not reported to the California Department of Public Health (CDPH) as required by facility policy and regulations. Interviews revealed that the DON and Administrator assumed the discoloration was due to the resident's agitated behavior and therefore did not consider it necessary to report the incident to CDPH. The facility's policy clearly states that all injuries of unknown origin must be reported to appropriate authorities and thoroughly investigated. The failure to report resulted in a delayed investigation by CDPH and created the potential for important information or facts to be lost or forgotten.