Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency (SA) for one resident. According to the incident report, the resident was found in bed with blood on her face, bed, floor, and in the trashcan. The resident was unable to recall what had happened or whether she had fallen. Nursing staff assessed the resident, noted a bump on her forehead, blood on her face, and abrasions to both elbows and knees, but could not determine the source of the bleeding. The provider was notified, and the resident was sent to the emergency room for further evaluation, where she was diagnosed with a contusion. Despite the unclear circumstances and the resident's inability to explain the injury, the incident was not reported to the SA as required for injuries of unknown origin. The interdisciplinary team later discussed the incident and concluded that the resident had likely fallen, but the administrator acknowledged that the incident should have been reported to the SA. The failure to report the incident meant that the SA was not able to review or investigate the potential neglect.