F0609

D

Failure to Report and Document Injury of Unknown Origin

Mount Vernon, Ohio Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an allegation of an injury of unknown origin to the State Survey Agency as required by policy and regulation. A resident with Alzheimer’s disease, severe cognitive impairment (BIMS score of 00), protein calorie malnutrition, major depressive disorder, and chronic kidney disease was dependent on staff for most activities of daily living and required monitoring for skin concerns during care. On the date in question, the resident’s family member observed a light purple bruise or discoloration on the resident’s right cheek while staff were assisting with lunch and reported it to an RN, who had not previously noticed the area and then notified the DON. The DON assessed the area and suggested it could have been caused by the resident’s cheek resting on a side rail during incontinence care, but staff interviews revealed no evidence that the resident’s face had come into contact with the bed rail.

Despite the family’s report and the DON’s stated intent to investigate, the incident was not fully documented or reported as required. The facility’s incident report did not specify the nature of the incident, and there was no skin assessment documented in the medical record on the date the bruise was identified. The bruise was not entered on the February incident/accident log, and review of the state’s Enhanced Information Dissemination Collection system showed no self-reported incident related to the resident’s facial discoloration for the relevant period. The DON confirmed that no self-reported incident was submitted regarding this injury of unknown origin, contrary to the facility’s abuse policy, which requires notification of the Ohio Department of Health within 24 hours and completion of an investigation within five days.