Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
During a recertification and complaint survey, it was found that the facility failed to report alleged violations involving abuse, neglect, or injuries of unknown source to the New York State Department of Health within the required timeframes. The facility's policy mandates reporting such incidents within 2 hours if serious bodily injury is involved, or within 24 hours if not, but this was not followed for several residents who experienced unwitnessed falls or injuries of unknown origin. One resident with rheumatoid arthritis and dementia was found on the floor with altered mental status and pain to the left hip, later diagnosed with a left intertrochanteric fracture. Despite the unwitnessed nature of the incident and the resident's inability to explain what happened, the event was not reported to the state. Another resident with vascular dementia and a history of traumatic brain injury was found with a head laceration, also unwitnessed and unexplained, and this incident was similarly not reported. In both cases, facility leadership acknowledged that such injuries of unknown origin are reportable but failed to ensure timely notification. A third resident with unspecified dementia experienced two separate unwitnessed falls, both resulting in injuries including facial fractures, lacerations requiring stitches, and a subdural hematoma. The resident was unable to explain the circumstances of the falls, and both incidents were not reported to the Department of Health as required. Interviews with facility administrators and the DON confirmed a lack of awareness or misunderstanding of reporting requirements for injuries of unknown origin, contributing to the deficiency.