Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency within the required 2-hour timeframe as mandated by state law and facility policy. According to the facility's policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source—must be reported immediately to the administrator and to the State Agency no later than 2 hours after the allegation is made. In this case, a resident with a history of falls, Type 2 Diabetes Mellitus, and Schizoaffective Disorder was found to have a red abrasion on the right hip and a wound to the right foot. The resident was cognitively intact and unable to recall or verbalize how the injury occurred. The injury was discovered and documented by the administrator, who subsequently sent the resident to the emergency room for evaluation. However, the incident was not reported to the State Agency until several days after the discovery, rather than within the required 2-hour window. During an interview, the administrator confirmed awareness of the injury and acknowledged that, since the cause was unknown and the resident could not explain it, it should have been classified as an injury of unknown origin and reported promptly as per policy and state law.