Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) as required. A resident with diagnoses including nontraumatic chronic subdural hematoma and a BIMS score of 00, indicating severe cognitive impairment, was found on the floor in an unwitnessed incident in the afternoon. Progress notes documented that the resident was found on the floor at approximately 2:30 p.m. and was later sent to the hospital at approximately 9:30 p.m. for further evaluation. A subsequent progress note indicated that the resident was admitted to the hospital with a left hip fracture, and a facility QA report confirmed the fall was unwitnessed. During a telephone interview, an RN stated the resident had been experiencing leg pain, which led the physician to order pain medication and an x-ray. Facility documentation showed that an internal incident report was completed, but there was no evidence that the injury of unknown origin was reported to the NJDOH. In an interview, the DON, in the presence of the LNHA, stated that the incident was considered a fall and not abuse and therefore was not reported to the NJDOH, and the LNHA stated the fall was not suspicious in nature and did not need to be reported. This was inconsistent with the facility’s Abuse and Neglect policy, which requires that all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation, be reported immediately, but not later than two hours after the allegation is made.
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