Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for six residents as required by both facility policy and state regulations. Policy review indicated that any incident of unknown origin or suspicious in nature must be reported to the State of Tennessee within two hours, regardless of the resident's medical conditions. Despite this, multiple incidents involving injuries such as skin tears, hematomas, abrasions, and discolorations were documented in resident records and incident reports without subsequent notification to the state agency. The residents involved were all cognitively impaired to varying degrees, with several being severely impaired and unable to communicate the cause of their injuries. For example, one resident was found with a skin tear to the right forearm of unknown cause, another with a 6-inch hematoma to the left forearm, and others with abrasions or discolorations, all of which were unexplained. In each case, the facility completed internal documentation and notified responsible parties or physicians, but did not report the incidents to the state as required for injuries of unknown origin. During an interview, the Administrator acknowledged that incidents of unknown origin should be reported but admitted that these specific cases were not reported. The Administrator also indicated a reliance on staff trust and did not provide evidence of investigations that would rule out abuse or neglect. This lack of reporting and investigation for injuries of unknown origin constituted a failure to comply with both facility policy and state requirements.