Failure to Report Unwitnessed Unexplained Injury as Required Under Abuse Policies
Penalty
Summary
A deficiency was cited under F609 for failure to timely report an unwitnessed, unexplained injury as a suspected abuse/neglect incident to the state agency, as required by regulation and the facility’s own policies. The resident involved was admitted with hemiplegia and hemiparesis following a cerebral infarction and had unspecified dementia. The MDS documented a BIMS score of 0, indicating severe cognitive impairment. During observation, the resident was seen in a wheelchair with a fading grayish-green discoloration above the right eyebrow, and the resident could not recall how the injury occurred. Family members reported to facility staff that they believed the resident had fallen out of bed during the night shift, resulting in the discoloration near the right eye, while the facility had no record of a fall. The Social Services Director stated that on learning of the discoloration, the family believed the resident had fallen sometime during the night, but the facility’s investigation could not confirm a fall. The Interdisciplinary Team discussed possible causes, including the resident bumping her head on the side rail or hitting herself while removing hand mittens, and the SSD acknowledged there was still a possibility the resident could have fallen, but the cause remained unknown. The ADON and DON both stated that the cause of the injury could not be definitively determined because it was unwitnessed, and the resident could not verify what happened. The DON acknowledged the injury was unwitnessed and unexplained but stated it was not reported to the California Department of Public Health because she did not think it was reportable. The Administrator, identified as the facility’s abuse coordinator, also stated the injury was not considered reportable because it was “light in nature.” These actions conflicted with the facility’s written policies on Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, Abuse, Neglect, and Exploitation, and Unexplained Injuries, which require that all allegations of abuse, neglect, exploitation, mistreatment, and injuries of unknown source be reported to the Administrator and appropriate agencies within specified timeframes and investigated under abuse procedures.
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