Failure to Timely Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin for Resident #4 to the State Survey Agency within the required timeframe. Facility policy and federal regulation require that all alleged violations involving abuse, neglect, exploitation, mistreatment, and injuries of unknown source be reported immediately, but not later than two hours if abuse or serious bodily injury is involved, or within 24 hours if not. Despite this, when Resident #4 was found with a swollen, bruised left index finger that was later confirmed by x‑ray to be an oblique fracture of the second proximal phalanx, the Administrator did not report the incident to the Department of Health because they did not believe abuse, mistreatment, or neglect had occurred. Resident #4 had significant cognitive and behavioral issues, including vascular dementia with mood disturbances, a history of stroke, aphasia, severe cognitive impairment, confusion, agitation, and combative behaviors with care such as hitting and grabbing staff. Care plans and resident care profiles documented noncompliance, rejection of care, poor safety awareness, and resistance to activities of daily living, with interventions focused on behavior modification and de‑escalation. On the morning of 10/14/2025, a CNA discovered swelling and bruising of Resident #4’s left index finger and knuckles during morning care and immediately reported it to an LPN, who then reported it to the RN Manager. Staff interviews confirmed that Resident #4 was known to be combative during care and that no prior concerns about the hand had been noted the previous night. The injury was treated as an injury of unknown origin by nursing leadership, who completed an incident report, notified the medical provider and family, and initiated an internal review by collecting staff statements going back 72 hours. The ADON and DON both stated that injuries of unknown origin are supposed to be reported to the Department of Health within a two‑hour window and that the Administrator is responsible for making such reports. The Administrator acknowledged that injuries of unknown origin, abuse, mistreatment, and neglect are to be reported within two hours of notification but chose not to report Resident #4’s injury because they believed no abuse had occurred and later stated that, in retrospect, they should have reported it as required by regulation.
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