F0609

D

Failure to Report Injury of Unknown Origin to Required Authorities

El Cajon, California Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The facility failed to ensure timely reporting of an injury of unknown origin for one resident to the California Department of Public Health (CDPH), the Ombudsman, and law enforcement, as required by its abuse reporting policy. The resident had a history of Alzheimer's disease and was documented on the MDS as rarely or unable to understand others or make herself understood, with severe cognitive deficits affecting decision-making. Nursing staff identified a change in skin condition with discoloration to the resident's left eye, described as a bruise of unknown origin, and the injury was unwitnessed. Despite this, there was no documentation that the incident was reported to the required external entities within the mandated timeframe.

Interviews with facility staff confirmed that the DON, Administrator, and Social Services Director were aware of the injury and considered it an injury of unknown origin, with staff speculating it may have occurred when the resident leaned her head against a padded bed rail. The DON and Administrator stated the facility did not report the incident because they relied on an El Cajon Police Department officer’s conclusion that there was no evidence of abuse, even though the officer had been notified of the injury through an external report and not by the facility. The Social Services Director and a licensed nurse both acknowledged that injuries of unknown origin should be reported to CDPH, law enforcement, and the Ombudsman within required timeframes, and the facility’s written policy stated that suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately to the administrator and other officials according to state law. Nonetheless, the required reports were not made by the facility.