Delayed Reporting of Injury of Unknown Source
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown source for one resident. Clinical notes indicated that the resident was first observed with discoloration and bruising on their left toe, which later was found to be a fracture of the fifth metatarsal bone in the left foot. The cause of the injury was unknown, and the facility's own investigation confirmed there was no probable cause for the injury. Despite policies requiring immediate reporting of such incidents, the injury was not reported to the State Agency until several days after initial observation and confirmation of the fracture. Staff interviews revealed that both nursing and administrative staff were aware of the requirement to report injuries of unknown origin immediately or within 24 hours. However, the report to the State Agency was delayed until staff connected the bruising and discoloration to the confirmed fracture. The delay in reporting was inconsistent with both facility policy and regulatory requirements, as staff did not act promptly upon first awareness of the injury.