Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the Department of Public Health (DPH) within the required two-hour timeframe. The resident, who had diagnoses including vascular dementia, depression, osteoporosis, history of stroke, and aphasia, was found by a nurse to have a red-purple, non-tender bruise above the right eyebrow during routine rounds. The nurse did not recall any prior documentation or report of the bruise and immediately notified the Unit Manager, who assisted in assessing the injury and initiating an incident report. Despite these actions, neither the nurse nor the Unit Manager was aware that such an injury of unknown origin required immediate reporting to DPH. The facility's policy mandates that any allegation of abuse, neglect, exploitation, mistreatment, or injury of unknown source must be reported to DPH immediately, but not later than two hours after discovery if it involves abuse or serious bodily injury. In this case, the injury was first identified and documented by nursing staff, but the required report to DPH was not made until six days later, after the hospital notified the facility of additional findings, including a non-displaced fracture and subarachnoid hemorrhage. Interviews with staff revealed a lack of awareness regarding the reporting requirements for injuries of unknown origin. The Director of Nursing confirmed that the facility's policy was not followed, as the nursing staff did not notify her immediately about the injury, and the report to DPH was significantly delayed. The deficiency centers on the failure to recognize and act upon the obligation to report the injury of unknown origin within the mandated timeframe, despite the facility's established policies and procedures.