Failure to Report Injury of Unknown Origin to Required External Agencies
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin for a severely cognitively impaired resident as required by law and by the facility’s own abuse reporting policy. The resident’s MDS indicated severe cognitive impairment and dependence on staff for most ADLs, including toileting, showering, transferring, and substantial assistance with eating, oral hygiene, and bed mobility. Multiple CNAs and LVNs observed a new bruise on the resident’s lower left chin/near the lip on or around 2/4/26, described as purple or purplish-blue, small, round or irregular, and approximately 1/4 to 1/2 inch in size. CNAs reported the bruise to charge nurses/LVNs, and documentation in the SBAR and skin assessment on 2/4/26 noted a new skin discoloration on the left chin area, with no complaints of pain or distress and the resident sleeping during the shift. Staff consistently stated they did not know what caused the bruise, and one CNA believed no one knew how it happened. Despite the unknown cause of the facial bruise and the resident’s severe cognitive impairment and dependence on staff, the administrator acknowledged that the bruise was not reported to CDPH, local law enforcement, or the Ombudsman. The facility’s written policy on Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, revised September 2022, states that all reports of resident abuse, including injuries of unknown origin, must be reported to local, state, and federal agencies as required by regulations, and that suspected injuries of unknown source must be reported immediately to the administrator and appropriate external agencies, including the state licensing/certification agency, the ombudsman, and law enforcement. Although the physician and resident representative were notified, the required external reporting to regulatory and protective agencies did not occur, resulting in the failure to ensure the injury of unknown origin was reported as required by law.
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