Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to follow its abuse policy requiring immediate reporting of all incidents and allegations of abuse, including injuries of unknown source, to the Administrator, Director of Nursing, and the State Survey Agency. The policy, last reviewed August 1, 2025, mandated such reporting, but this did not occur for one resident. The resident involved had diagnoses including hemiplegia, stroke, and dementia, was cognitively impaired, required staff assistance with toileting and personal hygiene, and was dependent on staff for transfers. On November 28, 2025, at 1:19 p.m., a nurse aide observed bruising to the resident’s right arm and right hip, and an RN assessed two faded purple bruises on the right hip and right upper arm, with the resident unable to recall how the bruises occurred, making this an injury of unknown origin. There was no documentation showing that this injury of unknown source was reported to the State Survey Agency as required by facility policy and applicable regulations. In an interview, the Director of Nursing confirmed that the facility did not report the incident to the State Survey Agency, resulting in a failure to timely report suspected abuse, neglect, or injury of unknown origin for this resident.
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