Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an injury of unknown origin sustained by a resident was reported in a timely manner to the state agency, as required by policy. The resident involved had multiple diagnoses, including dementia with behavioral disturbance, malnutrition, and late-onset Alzheimer's disease, and was dependent for all activities of daily living and mobility. The resident was known to have fragile skin and was to wear protective geri-sleeves, and required transfers using a Hoyer lift. On the morning of the incident, staff discovered a significant skin tear on the resident's arm after a Hoyer transfer, but there was no clear indication of how the injury occurred. Staff interviews revealed that the nurse on duty was informed of the injury but did not immediately investigate or ask staff present about the cause. The incident report was incomplete at the time of the initial documentation, with the section regarding the cause of the injury left blank until after the facility's investigation was completed. The Director of Nursing was not informed of the injury until the following day during a care conference with the resident's family. The facility's investigation later suggested the injury may have been caused by a buckle on the resident's Broda chair, but this determination was made after the fact. Despite the facility's policy requiring timely reporting of injuries of unknown origin to the state agency, the incident was not reported until several days later, after the resident's family raised concerns. Multiple staff, including the DON and ADON, acknowledged that the cause of the injury was not immediately known and that reporting should have occurred promptly. The delay in reporting constituted non-compliance with regulatory requirements for timely notification of suspected abuse, neglect, or injury of unknown origin.