Failure to Timely Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the State Survey Agency (SSA) as required by regulation and its own abuse policy. A resident with dementia and weakness was admitted to the facility and later was found lying on the floor, complaining of right leg pain. The Incident/Accident Report for this event documented that the incident was unwitnessed and that the resident was not interviewed about what had occurred. The resident was emergently transferred to the hospital for medical intervention following this event. A written statement from the Executive Vice President/Chief Operating Officer and Chief Clinical Officer indicated that the former Administrator did not report this incident to the SSA as an injury of unknown origin, despite the circumstances of the resident being found on the floor, in pain, and requiring emergency transfer. Review of the facility’s policy titled “Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property” showed that all injuries of unknown source must be immediately reported to the Administrator, DON, and the applicable State Agency, and that allegations involving abuse or serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. An attempt to interview the former Administrator was unsuccessful.
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