Failure to Report Injury of Unknown Source as Alleged Abuse
Penalty
Summary
The facility failed to ensure that an alleged violation involving possible abuse was reported to the New York State Department of Health within the required timeframe. Facility policy on Abuse Prevention required that all alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, be reported to proper authorities, and that alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediately, but not later than 2 hours after the allegation is made if the events involve abuse or result in serious bodily injury. For one resident, an unwitnessed injury to the upper right eyelid was not reported to the Department of Health as required. Resident #426 had diagnoses including Alzheimer's disease, cognitive communication deficit, and depression, and was documented as having severely impaired cognition and requiring partial assistance of one person for ADLs. On the date of the incident, a CNA observed redness on the resident’s right upper eyelid at 8:15 AM; when interviewed, the resident initially stated they had fallen, but later stated they did not know what had happened. An LPN documented that the resident had a bump over the right eye and that the resident could not state how or when they fell. The DON stated that an investigation was conducted and, based on the resident’s initial statement that they had fallen, the facility concluded the injury was from a fall. The DON also acknowledged that the resident was confused and could not fully state what happened, and that the injury to the resident’s right eye was not reported to the Department of Health because the facility had already completed its investigation.
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