Failure to Report Injury of Unknown Source on Resident’s Hand
Penalty
Summary
The facility failed to timely report an injury of unknown source for one of five sampled residents, delaying investigation by the California Department of Public Health. The resident had COPD, generalized muscle weakness, moderate cognitive impairment, and was dependent on staff for ADLs and bed mobility. On observation, the resident had yellowish‑purplish discoloration on the left dorsal hand and stated it occurred after someone took her blood pressure too tightly on that hand, but could not recall when or who did it. The discoloration met the definition of an injury of unknown source because the event was not observed, could not be clearly explained by the resident, and involved suspicious discoloration. The Treatment LVN reported first identifying redness on the resident’s left dorsal hand on 1/2/2026, attributing it to a BP cuff being too tight, and stated the resident could not provide when or who caused it. The Treatment LVN reassessed the left dorsal hand on 1/21/2026 but did not document this in the progress notes. A wound MD later examined the area and identified it as ecchymosis. A CNA reported that on 1/21/2026 she observed yellowish‑purplish discoloration on the same hand and notified an LVN. A photograph taken on 1/23/2026 showed discoloration consistent with what the CNA had seen earlier. Despite these observations and notifications, the injury of unknown source was not reported as required, resulting in a delay in external investigation.
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