Failure to Timely Report Unwitnessed Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of an unwitnessed incident involving a resident who was found on the floor with injuries of unknown origin. According to the facility's policy and state regulations, all alleged violations involving abuse, neglect, or injuries of unknown source must be reported immediately, but not later than 2 hours if abuse or serious bodily injury is suspected, or within 24 hours if not. In this case, a resident with diagnoses of epilepsy and Alzheimer's disease was found on the floor with swelling to the forehead, left peri-orbital swelling, and an abrasion on the nose. The resident was unable to explain the occurrence due to cognitive impairment, and the incident was not witnessed by staff. Documentation showed that the incident was assessed by a Registered Nurse, who noted the injuries and arranged for the resident to be transferred to the hospital for further evaluation. The facility's Accident Investigation Report recorded the event and the injuries, but there was no documented evidence that the incident was reported to the New York State Department of Health as required by policy and regulation. Interviews with the DON, Medical Doctor, and Administrator revealed that the incident was attributed to a fall, and since there was no fracture or major injury, it was not considered reportable by the facility's leadership. Despite the facility's policy requiring reporting of injuries of unknown origin, the unwitnessed nature of the incident and the resident's inability to explain the injuries were not considered sufficient to trigger a report to the state. The lack of camera footage and the resident's history of falls were cited as reasons for attributing the incident to a fall rather than an injury of unknown source. As a result, the required notification to the Department of Health was not made.