Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of an injury of unknown origin to the State Agency, affecting one resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident, who had multiple complex medical conditions including anoxic brain damage and dysphagia, was found to have multiple scratches on the left arm during a skin evaluation. There was no documentation in the medical record or progress notes regarding the origin of the scratches, and no physician orders were made for their treatment. An incident report was opened in error and not completed, and no Self-Reported Incident (SRI) was filed for this event. Interviews with facility staff revealed that the DON did not properly address the incomplete skin evaluation and could not locate documentation explaining the scratches. The RN who assessed the resident's scratches did not initiate treatment orders or complete the required risk documentation, and only notified the family, who were already aware. The DON confirmed that the incident was not investigated to determine the cause of the injury, which met the facility's definition of an injury of unknown origin and should have been reported and investigated according to policy. The facility's failure to report and investigate the injury constituted non-compliance as identified during a complaint investigation.