Failure to Timely Report Injuries of Unknown Source Following Unwitnessed Falls
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported within the required timeframes to the administrator and appropriate authorities. Specifically, the Director of Nursing (DON) did not identify unwitnessed falls resulting in injuries for two residents as alleged violations of injury of unknown source. As a result, these incidents were not reported to the administrator or to the State Survey Agency within 24 hours as required by state law and facility policy. One resident, who had diagnoses including acute respiratory failure, dementia, muscle wasting, and sepsis, experienced an unwitnessed fall resulting in a laceration to the right eyebrow with swelling and bleeding, requiring transfer to the hospital. The resident had moderately impaired cognition and required substantial assistance with mobility. Despite the severity of the injury and the resident's inability to explain what happened, there was no incident report documented in the electronic medical record, nor was a report submitted to the state agency. Similarly, another resident with severe cognitive impairment and a history of repeated falls was found on the floor with a hematoma and laceration after an unwitnessed fall. This incident was also not reported to the state agency as required. Interviews with staff revealed that while they were knowledgeable about abuse, neglect, and exploitation (ANE) reporting protocols and had received recent training, the DON and administrator did not follow established procedures for reporting unwitnessed falls with injuries of unknown source. The DON stated that she did not submit ANE reports for these incidents because she believed the residents could explain their falls, despite one resident having severe cognitive impairment. The administrator also indicated uncertainty about whether the incidents met the threshold for reporting, and there was a lack of documentation and timely notification to authorities as required by facility policy and state regulations.