Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to timely report injuries of unknown origin (IUO) for three residents, as required by facility policy and state regulations. In one case, a resident with severe cognitive impairment was found with a large bruise on her left hand while in the dining room. Although the injury was observed and reported internally to the medical doctor, responsible party, and unit manager, the incident was not reported to the state agency until three days later. Staff interviews confirmed that the injury was unwitnessed, the resident was unable to provide a statement due to dementia, and the facility's policy required reporting IUOs within two hours of discovery. Another resident, also with severe cognitive impairment, was discovered with a large bruise on the left upper extremity after being transferred between units. The resident had no recall of injury or trauma, and staff statements indicated no witnessed incident. The IUO was not reported to the state agency until several days after discovery, despite staff and administrative interviews confirming that such incidents should be reported immediately and within two hours if the cause is unknown. A third resident was found with a bruise of unknown origin on the upper left side of the forehead. The injury appeared to be in the healing stage, and no staff could confirm any fall or incident that could have caused it. The incident was not reported to the state agency within the required two-hour timeframe. Facility policy clearly defined immediate reporting requirements for suspected abuse, neglect, or IUO, but these were not followed in these cases, as confirmed by staff and administrative interviews and documentation review.