Failure to Properly Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely and properly report an injury of unknown origin for one resident (R7) to the state surveying agency, as required by regulation and the facility’s Abuse Prevention Program policy. Surveyors requested Facility Reported Incidents (FRIs) for the prior three months and were provided only three incidents dated 12/02/25, 12/16/25, and 01/14/26. During review, surveyors observed that these incidents had not been submitted to the correct state agency email address. The Administrator (V1) stated she became aware of R7’s incident from the DON (V2) and believed she had reported it to the state agency via email on 12/16/25, the same day it was reported to her. When asked to provide confirmation of successful submission, V1 was unable to access her email initially and later reported she had not received confirmation because the email was returned as undeliverable. Further review showed that V1 also asserted that V2 had emailed R7’s incident to the state agency, but the only documentation produced to the surveyor were scanned emails showing time stamps of blank emails (one undeliverable and one sent to the correct address) with no FRI attached. When the surveyor requested that V1 forward the original email with the attached reportable incident, this was not provided. Record review confirmed that no FRI for R7 had been received by the state agency and that no FRIs from the facility had been received since 12/03/25. V1, who had been Administrator since 08/2024, stated she was unaware she had been using an incorrect email address and acknowledged that she never received confirmation of successful submissions. V1 also reported using an incorrect fax number for the state agency. The facility’s Abuse Prevention Program policy requires all personnel to promptly report any incident or suspected incident of abuse, mistreatment, neglect, including injuries of unknown origin, but this did not occur for R7’s injury of unknown origin.
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