Failure to Timely Report Injury of Unknown Origin as Required
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin as a suspected abuse/neglect incident to the State Agency (SA) within the required two-hour timeframe. Facility policy, revised 02/19/25, states that all staff must immediately report any allegation or suspicion of abuse, neglect, exploitation, or mistreatment, and that initial reports to the Department of Health must be made within two hours if the incident involves serious bodily injury and/or is related to abuse/neglect. Resident 104, who had dementia and a BIMS score of 0/15 indicating severely impaired cognition, was re-admitted on an unspecified date and had diagnoses including dementia, muscle weakness, and a bone density disorder, and was on anticoagulant therapy with a care plan for risk of bruising and bleeding. On 09/14/25 at 11:20 PM, CNA2 informed LPN4 during shift report that the resident had a hematoma/bruise on the left elbow, discovered when CNA2 began the 11–7 shift and changed the resident. CNA4, who had been assigned to the resident on the 3–11 shift, stated he had not seen the hematoma because the resident was wearing arm sleeves, and the 7–3 nurse had not reported any skin changes. The nursing note documented that there was no evidence of the injury of unknown origin being reported to the supervisor at that time. The facility’s initial Facility Information Report to the Department of Health was dated 09/15/25 and indicated the resident had a bruise to the left elbow and was unable to say what occurred. Interviews revealed that LPN4 did not notify the supervisor when the unwitnessed injury was identified and instead spoke with the DON the next morning, and the DON stated he was unaware that an injury of unknown origin should be reported to the SA within two hours of knowledge of the incident. The Administrator acknowledged the two-hour reporting requirement for abuse allegations but stated that, in their understanding, injury of unknown origin had a 24-hour reporting timeframe and that the facility does not contact police, leaving that to the resident or family.
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