Failure to Timely Report Injury of Unknown Origin as Suspected Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin as potential abuse in accordance with its Abuse Investigation and Reporting policy. A resident with severe cognitive impairment, ventilator dependence, a history of nontraumatic intracerebral hemorrhage, and a tracheostomy was admitted with significant functional dependence for toileting hygiene, personal hygiene, and bed mobility. On 1/27/2026, a Change of Condition (COC) documented that the resident was noted with discoloration on the right eye, further described as dark purple discoloration with intact but discolored skin. The Director of Nursing (DON) later observed greenish to yellowish discoloration with a small linear red mark at the right corner of the eye and acknowledged that the cause of the bruise was unknown. Staff interviews showed that multiple staff members observed the discoloration but did not initiate or complete required abuse reporting. The Treatment Nurse (TN) stated he first saw the right eye discoloration on 1/27/2026 after being informed by the RN Supervisor (RNS), describing it as light purple discoloration. TN reported the discoloration only to the physician and responsible party and did not measure the area or report it as suspected abuse. The RNS reported seeing redness under the resident’s eyes on 1/27/2026 but was not informed of TN’s assessment of dark purple discoloration and stated that, had she been informed, it should have been reported to the Administrator and then to CDPH, police, and Ombudsman as suspected abuse. A CNA reported that on 1/28/2026 she entered the room, turned on the light, and saw what she described as a “black eye,” with purple discoloration under and to the right side of the eye. The Administrator and DON confirmed that the facility’s policies required that injuries of unknown source be treated as potential abuse and promptly reported to local, state, and federal agencies, including immediate notification of law enforcement, and that “promptly” meant within two hours of observing suspected abuse. The Administrator stated that, under the Investigating Resident Injuries policy, an injury of unknown source should trigger the abuse reporting and investigation protocols. The DON stated she was not informed of the resident’s right eye dark purple discoloration when it was first noted and that the injury met the definition of an injury of unknown origin that should have been reported within two hours. The LVN also acknowledged noticing discoloration on the right side of the resident’s eye on 1/27/2026 and not reporting it to CDPH, Ombudsman, or police. As a result, the injury of unknown origin was not reported to CDPH, local law enforcement, or the Ombudsman within the required two-hour timeframe, delaying the investigation.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.