Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) after swelling and bruising were identified on a resident’s right hand. The resident had diagnoses including muscle weakness and functional quadriplegia and a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment. On 12/01/25, the resident’s care plan documented a focus area of swelling and bruising to the right hand, but there was no corresponding report of this injury to NJDOH as required for suspected abuse, neglect, or injury of unknown origin. A review of the facility’s Reportable Event submitted to NJDOH on 12/05/25 showed that it did not address the bruise and swelling on the resident’s right hand. During an interview on 1/29/26, the DON stated that the facility could not provide any documented evidence that the swelling and bruise identified on 12/01/25 had been reported to NJDOH. This failure occurred despite the facility’s Abuse, Neglect and Exploitation policy, revised 9/01/25, which required all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified time frames, depending on whether abuse or serious bodily injury was involved.
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