F0609

D

Failure to Timely Report Injuries of Unknown Origin to State Authorities

Rockville, Maryland Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

Facility staff failed to timely report injuries of unknown origin for two residents to the State of Maryland's Office of Health Care Quality (OHCQ). For one resident, a family member noticed a contusion on the resident's right upper arm while visiting and reported this skin issue to the assigned Geriatric Nursing Assistant (GNA) at approximately 2:30 PM. The family member asked that the resident not be disturbed because the resident was asleep, and the GNA did not assess the resident at that time. The GNA then unintentionally failed to report the family’s concern or the potential injury to a nurse or any other staff member before leaving for the day. The facility did not become aware of the injury until the family member emailed the Assistant Director of Nursing (ADON) several days later, at which point the injury of unknown origin was reported to OHCQ, resulting in a four-day delay from when the family first identified and reported the potential injury to staff.

In a separate incident, another resident was observed by nursing staff with a bruise to the right thigh that was treated and documented as an injury of unknown origin. Nursing staff reported this injury to the Dementia Unit Manager, but the Dementia Unit Manager did not notify the Director of Nursing (DON) or the Administrator on the date the injury was discovered. Administration only became aware of the injury several days later when the Dementia Unit Manager reviewed the nursing documentation and recognized that the injury met criteria for an injury of unknown origin. The injury was then reported to the DON and subsequently to OHCQ, but this delay caused the facility to report the injury to the state agency late. Both incidents were confirmed through staff interviews and review of the facility-reported incident investigations.