F0609

D

Failure to Timely Report Injuries of Unknown Origin to DHSS

Columbia, Missouri Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

Facility staff failed to report an allegation of bruises and injuries of unknown origin for one resident to the Department of Health and Senior Services (DHSS) within the required 24-hour timeframe. The facility’s abuse investigation and reporting policy, revised 07/2017, required that alleged violations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property be reported immediately, but not later than 24 hours if the alleged violation did not involve abuse with serious bodily injury. The resident, who had been admitted from home for a planned five-day stay and then discharged back home, had a documented resident representative. The representative first reported to the DON that, after returning home, the resident had an abrasion to the left side, a laceration approximately 0.5 inches above the left ear, bruising under the left armpit, and a lump to the back, but did not specify abuse or neglect or accuse anyone.

The next day, the resident representative made a second report to the administrator, again describing a lump to the left forehead, a laceration above the left ear, bruising to the left side/underarm, and excoriation to the genitals. Despite these reports, the facility did not notify DHSS within 24 hours of the initial allegation of bruises and injuries of unknown origin. The DON acknowledged that, based on the information received from the resident representative and staff interviews, DHSS should have been notified within 24 hours of the initial report. The administrator also acknowledged that staff should have made an initial report to DHSS within the required timeframe but did not do so, and the DHSS complaint/facility self-report database contained no report from the facility until more than 48 hours after the allegations were first reported to facility staff.