Failure to Timely Report Injuries of Unknown Source to State Agency
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that alleged violations, including injuries of unknown source, be reported immediately to the Administrator or designee and to the State Agency within 24 hours, with investigation results reported within five working days. Policy review showed that alleged violations were to be reported to the Office of Healthcare Licensing and Surveys and the Department of Family Services within the specified time frames. However, review of the State Agency incident database showed that no incidents had been reported since April 26, 2025, despite the occurrence of injuries of unknown source for two residents. For one resident, nursing progress notes documented that in the early morning hours the CNA notified the RN that the resident was complaining of left-sided chest pain and had screamed when being rolled for incontinence care. The resident rated the pain as 8/10 and described it as sharp, stating it began the previous morning when getting up in a sit-to-stand. The RN contacted the on-call provider, and the resident was transferred to the ED, where the diagnosis was chest wall contusion and Lortab was prescribed. For another resident, a nurse progress note documented that bruising, red/purple in color, was observed around the anus. These injuries were unexplained, yet there was no corresponding report in the State Agency incident database, and the DON confirmed that the facility’s policy had not been followed and that no incidents had been reported to the State Agency since April 2025.
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