Failure to Report Scald Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the state Department as required by regulation. A resident with Alzheimer's disease, admitted in June 2024, had an MDS dated 12/22/25 indicating no cognition score could be determined. On 2/19/26, staff notified a nurse of blisters on the resident's right hand with an unknown cause, and the resident exhibited facial grimacing when the area was touched. An IDT skin management note on the same date documented a right dorsal hand scald injury measuring 8.0 x 6.0 x 0.1 cm, with the appearance consistent with a scald injury and no documentation of the cause. A physician order dated 2/27/26 directed daily treatment to the right dorsal hand scald injury with cleansing, bacitracin ointment, xeroform, and dry dressing until 3/12/26. On 3/4/26, the resident was observed in the dining room with a bandage on the right hand. During interviews, the treatment nurse confirmed that the wound provider identified the wound as a scald injury and that the injury was of unknown cause. The DON confirmed there was no witness to the incident, that the resident sustained an injury of unknown origin, and that the wound doctor categorized the injury as a scald. The Administrator confirmed the injury was of unknown cause and acknowledged that he did not report the incident of unknown origin to the Department, resulting in a delay of the Department’s investigation. Facility policies on identifying types of abuse and unusual occurrence reporting defined physical abuse to include unexplained injuries and required reporting of allegations of abuse and unusual occurrences to appropriate agencies within 24 hours, but this incident was not reported as required.
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