Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency for one resident. The resident was admitted with metabolic encephalopathy, dementia, and a history of transient cerebral ischemic attack, and had a BIMS score of 7/15 indicating severely impaired cognition. The resident’s care plan identified a history of falls and increased fall risk related to deconditioning, poor safety awareness, impulsivity, muscle weakness, unsafe transfer behavior, medications, and prior falls, with interventions including following post-fall protocol, assessing for injuries, monitoring vital signs, and notifying the physician. Another care plan problem addressed impaired cognitive function related to dementia, with interventions to cue, reorient, and supervise as needed. On one morning, a PTA documented that during a therapy session the resident was noted to have increased edema on the right forearm and was unable to explain what happened or quantify pain due to cognitive impairment; nursing was notified. Later that morning, an LPN documented a hematoma to the resident’s right forearm, noted signs of pain, administered pain medication per physician order, and notified the NP. The NP’s progress note described right arm swelling in a resident with multiple falls and advanced dementia, with the resident unaware of the swelling and denying pain, and with full range of motion and intact circulation in the affected arm. During interviews, the Administrator stated that for their state, insignificant or non-serious injuries of unknown source did not have to be reported, and the DON confirmed the incident was not reported to the state. This was inconsistent with the facility’s abuse/neglect/mistreatment policy, which required that all alleged incidents, including injuries of unknown source, be reported to the Administrator or designee and then to appropriate regulatory agencies and/or law enforcement.
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