Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source to the New York State Department of Health as required by policy and state regulations. A resident with diagnoses including hemiplegia, contracture, pain, and schizophrenia was found with swelling and discoloration of the right 4th finger, which was acquired in-house and could not be explained by the resident. Medical assessments and x-ray confirmed a dislocation and fracture of the finger, and the resident was transferred to the emergency department for further evaluation and treatment. There was no witness to the occurrence, and the resident was unable to account for how the injury happened. Despite the unexplained nature of the injury and the facility's policy requiring immediate reporting of injuries of unknown source, the incident was not reported to the Department of Health. Facility leadership, including the Clinical Director of Nursing and the DON, determined that the injury was likely self-inflicted and therefore not reportable, citing the absence of a witness and the resident's inability to identify a cause or responsible party. The decision not to report was based on their belief that the injury was obvious in origin and not suspicious, despite documentation indicating the cause was unclear.