Failure to Timely Report Unwitnessed Injury of Unknown Source to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an unwitnessed injury of unknown source to the California Department of Public Health (CDPH) within the required 24-hour timeframe for one resident. The resident had diagnoses including metabolic encephalopathy, epilepsy, dementia, and muscle weakness, with documentation showing fluctuating decision-making capacity and severely impaired cognition. The Minimum Data Set indicated the resident required partial to moderate staff assistance for toileting hygiene, showers, and dressing. A Change of Condition note documented that the resident developed discoloration and swelling under the left eye, described as a dark purplish color. On observation, the resident was noted to have a large dark bruise partially around the left eye and was unable to explain how the injury occurred. Interviews and record reviews showed that the DON and LVN recognized the injury as an injury of unknown source, given that the incident was unwitnessed and the resident could not provide an explanation, consistent with the facility’s policy defining injuries of unknown source. Both the DON and LVN stated that such injuries should be reported within two hours federally and within 24 hours to the state. The facility’s “Unusual Occurrence Reporting” policy required notification to the Department of Health Services of all unusual occurrences, including facility-related injuries requiring medical treatment and other injuries affecting health and safety, within 24 hours. Despite this, the unwitnessed facial injury and resulting discoloration to the resident’s left eye were not reported to CDPH within the required timeframe, constituting the cited deficiency.
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