Failure to Report Injury of Unknown Source as Required
Penalty
Summary
The facility failed to report an injury of unknown source to the Department as required by its abuse policy and state and federal regulations. A resident with a history of hemiplegia, hemiparesis, dysphagia, and anxiety disorder was found with an unexplained bruise and bump on the left side of her forehead. The injury was discovered by a CNA and assessed by a licensed nurse, who documented the findings, notified the treatment nurse, physician, and the resident's responsible party, but did not report the incident to the Department. The licensed nurse and the Director of Nursing assumed the injury was self-inflicted due to the resident's history of scratching herself, although there was no documentation or witness to support that the resident had ever hit herself in the head or face. The responsible party confirmed that while the facility regularly communicated about the resident's scratching behavior, she had never been informed of any self-hitting behavior. The facility's own investigation could not determine the cause of the injury, and no staff or resident could explain or had witnessed the event. Despite the facility's policy requiring the reporting of injuries of unknown source, especially those involving the face or head, the incident was not reported to the Department. The Administrator acknowledged that the injury should have been reported and recognized the importance of such notifications for thorough investigation and resident safety. The failure to report denied the Department the opportunity to conduct a timely investigation into the unexplained injury.