Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of potential abuse within the required two-hour timeframe for a resident with an injury of unknown origin. The resident, who was severely cognitively impaired and required substantial assistance for transfers, was observed to have multiple bruises and a scabbed scratch on the right hip and lower extremities over several days. Despite ongoing documentation of pain, bruising, and changes in condition, the initial bruising was not reported to the state agency as required, and an investigation was not promptly initiated. The resident had a complex medical history, including atrial fibrillation managed with anticoagulant therapy, dementia, arthritis, and a history of falls. Staff documented increasing right hip pain, grimacing, and significant bruising that expanded over time. Multiple staff members, including nursing assistants and LPNs, observed and documented the bruising and pain, but there was a delay in notifying the Director of Nursing, administrator, and state authorities. The resident was unable to recall the cause of the injuries due to cognitive impairment, and staff interviews confirmed that the bruises were of unknown origin and should have been reported immediately. Facility policy required that all allegations of abuse, neglect, or injuries of unknown origin be reported to the appropriate authorities within two hours. However, the report to the state agency was not made until several days after the initial identification of the bruising. Interviews with staff and review of documentation revealed that the required notifications and investigation were not initiated in a timely manner, resulting in a failure to protect the resident as outlined in facility policy and regulatory requirements.