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 (SA) for a hospice respite resident. The resident was admitted for a five-day hospice respite stay with diagnoses including unspecified dementia, chronic respiratory failure, and a history of falling. On admission, documentation showed pain 0/10 and skin findings limited to right ankle discoloration and slight redness to the front peri area. A subsequent skin check documented no skin issues. At discharge, however, staff identified discoloration to the upper left shoulder described as purplish/yellow. The DON assessed the area and noted it appeared to be from pre-trauma prior to admission, and an Incident/Accident (IA) report was completed. The IA report documented that the charge nurse discovered the discoloration during a pre-discharge skin assessment, that the DON observed purple and yellow coloration suggesting healing, and that the facility could not identify a fall or other cause for the bruise based on staff interviews. Further information from hospice staff indicated that hospice CNAs did not observe bruising on one visit but noted bruising to the left shoulder area on a later visit when providing a shower, and the facility was unable to determine the cause of the bruise. Imaging performed after discharge showed a healed or healing nondisplaced femoral neck fracture of the left hip, consistent with a non-acute fracture. The Administrator/Abuse Coordinator acknowledged in interview that the cause of the bruise could not be determined and stated they should have reported the injury of unknown origin to the SA. The facility’s Abuse Prohibition Policy required that allegations of abuse or neglect and incidents resulting in injury be thoroughly investigated, documented, and reported to appropriate state agencies, with notification to state or federal agencies within two hours if there was an abuse allegation or serious injury. Despite this policy and the unknown cause of the shoulder injury, the facility did not report the injury of unknown origin to the SA.
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.