Failure to Immediately Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an alleged violation involving possible abuse was reported immediately to the Administrator as required by policy. Specifically, a resident with severe cognitive impairment and multiple complex diagnoses, including Type 2 diabetes, seizure disorder, autistic disorder, and cerebral palsy, was found to have several yellow-colored, faded bruises under the upper part of his right arm. The resident's responsible party (RP) noticed the bruising and reported it directly to an LVN, who documented the finding in the nurse's notes but did not escalate the report to the ADON, DON, or Administrator. The LVN assessed the resident, who was unable to communicate how the bruising occurred due to his cognitive impairment, and noted that the resident was not in distress or acting outside his normal behavior. Despite being trained on the facility's policy to report bruises of unknown origin, the LVN did not notify supervisory staff or the Administrator, as required. There was no incident report or grievance filed regarding the bruising, and neither the ADON, DON, nor the Administrator were made aware of the incident until it was brought to their attention during the survey. Facility policy clearly states that all employees must report any allegation of abuse, neglect, or misappropriation of resident property to the Abuse Coordinator immediately, and that all incidents of unknown origin must be investigated. The failure to report the bruising as required resulted in the incident not being investigated in a timely manner, as the appropriate facility leadership was not informed.