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Based on interview and document review, the facility failed to report an injury of unknown origin to the State Agency (SA) for 1 of 1 (P1) patient reviewed for injuries of unknown origin.

Findings include:

P1's progress note dated 10/28/24 at 8:00 a.m., indicated P1 had an abrasion to the left forearm which was visible, dry, maroon/purple, no drainage. P1 also had an abrasion on the left arm which was visible, dry, maroon/purple, no drainage.

The Midwest Children's Resource Center (MCRC) consultation from medical doctor (MD)-A dated 10/31/24, indicated P1 was a 2-month-old baby who was born at 31 weeks' gestation. P1's diagnoses included infant of a diabetic mother syndrome, preterm, delivered via cesarean section and slow feeding. P1 had never left the hospital and had unexplained bruising. The bruising was first documented the morning of 10/28/24 by registered nurse (RN)-A. MD-A summarized, "The bruising is patterned and most consistent with a squeeze injury. There is no history of any medical interventions, such as blood draws that would require significant holding of her left arm in the days preceding the bruising. She has no laboratory evidence of underlying coagulopathy. Her injury is most consistent with an abusive injury, where excessive force was applied to her left arm, resulting in patterned bruising. This would not be expected in the course of routine care of an infant. Plan: risk is involved, will make reports to law enforcement."

On 11/5/24 at 12:36 p.m., RN-A stated she noticed the bruising on P1 the morning of 10/28/24 at around 8 a.m. She reported it to the charge nurse about 3 to 4 hours after discovery.

On 11/5/24 at 1:09 pm., the director of risk and compliance (DRC)-A stated an internal investigation substantiated something happened to cause P1's bruising, but they were unable to determine what happened or by who. Within 18 hours of the bruise being identified, it was brought to the attention of risk management. Risk management determined what agencies to report to. The concern was reported to MCRC and the police. The police would usually report to the SA; they (police) would determine if a concern should be reported to the SA after the police conducted their own investigation.

The facility policy Patient Safety and Adverse Health Events dated 7/15/22, directed the Patient Safety Executive Committee determines if an event is reportable under any applicable statutory, regulatory, or accrediting agency requirements.