Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the State Agency as required by policy and regulation. One resident with dementia with agitation, cognitive communication deficit, and Parkinson’s disease with dyskinesia had significant ADL and mobility deficits and required extensive staff assistance, including two-person assist and a mechanical lift for transfers. The resident’s care plan reflected these needs. On the morning of 2/18/26, while the resident was seated in a wheelchair at the nurse’s station, an LPN observed a hematoma on the left side of the resident’s forehead. No one had witnessed how the injury occurred, and the cause was unknown at the time it was discovered. Staff concluded that the resident had likely hit their head on the bed’s headboard earlier in the morning due to intermittent dyskinesia. The Assistant Director of Nursing (ADNS) consulted with the Regional Director of Clinical Services (RN #3) and reported that the injury could be explained by dyskinesia, leading RN #3 to determine that the event did not need to be reported as an injury of unknown origin within the 24-hour reporting window. The ADNS did not follow the facility’s abuse policy requirement to conduct a complete investigation by interviewing all staff with access to the resident in the prior 72 hours; instead, only the two NAs from the previous shift were interviewed, and the unit nurse who had interacted with the resident minutes before the hematoma was noted was not interviewed. The facility’s policy defined an injury of unknown source as one not observed or not explainable by the resident and suspicious due to its extent or location, and directed reporting of such events to the State Agency within specified time frames. Because the investigation was incomplete and the source of the injury remained unwitnessed and unexplained, the injury met the facility’s definition of an injury of unknown origin, but it was not reported to the State Agency.
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