Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or injuries of unknown source were reported immediately, but not later than two hours after the allegation was made, for one resident whose records were reviewed for suspicious injuries. The resident in question had a history of cerebral infarction and unspecified dementia, with severe cognitive impairment and disorganized thinking. She resided in a secure care unit due to her dementia and risk for elopement, and required supervision for mobility and activities of daily living. On the date in question, the resident was noted to have bruising on her right temple and left hand, with the temple bruise later worsening and requiring hospital evaluation. Staff interviews and record reviews revealed that the initial discovery of the bruising was made during a shift change, with the night nurse reporting the findings to the day nurse. The day nurse assessed the resident, notified the physician, and reported the findings to the ADON/DON. However, the incident was not reported to the administrator until the following day, rather than immediately as required by facility policy and state regulations. The administrator confirmed that she was not informed of the incident until the next day, and that the required report to the state was made only after she became aware of the situation. The facility's policy required immediate verbal reporting of suspected abuse, neglect, or injuries of unknown source to the Abuse Preventionist or designee, and for the administrator to report qualifying incidents to the state within the required timeframe. Despite these policies, the delay in reporting the resident's injury of unknown origin resulted in noncompliance with regulatory requirements. The deficiency was identified through observation, interviews with staff and the resident's physician, and review of medical records and facility policies.