Failure to Timely Report Injury of Unknown Source Due to Reporting System Access Issues
Penalty
Summary
The facility failed to report an incident of injury of unknown source to the State Agency in a timely manner for one resident. The incident involved a resident with severe cognitive impairment, who was found with a large, purplish bruise on her left forearm above the elbow. The resident was unable to explain how the bruise occurred, and staff who worked prior to the incident did not observe the bruise. The resident had recently been on a leave of absence with her guardian to get her hair done, and upon return, did not report any pain related to the bruise. The nurse notified the DON, who then attempted to notify the Administrator, but the Administrator was out of town at the time. The facility's policy required immediate reporting of such incidents to the Administrator and DON, and notification to State or Federal agencies within specified timeframes. However, the DON, who was the backup Abuse Coordinator, was unable to access the reporting system due to ongoing technical issues that had not been resolved since August. As a result, the incident was not reported to the State Agency until several days after it was discovered. The NHA acknowledged the lack of follow-up regarding the DON's access to the reporting system, which contributed to the delay in reporting.