Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source within two hours of being informed that a resident sustained a serious bodily injury, as required by their abuse and neglect policy. The policy mandates that allegations of abuse, neglect, exploitation, or injury of unknown origin resulting in serious bodily injury must be reported to state agencies within two hours. In this case, a resident with severe cognitive impairment, dementia, and a history of osteoarthritis and osteoporosis was found to have a minimally angulated fracture of the proximal neck of the left humerus. The injury was identified after the resident exhibited swelling and pain in the left shoulder, prompting an x-ray ordered by the physician. The x-ray results, which indicated a fracture, were received and sent to the physician between 6:30 PM and 7:00 PM, with the physician responding around 9:30 PM. Despite the facility becoming aware of the injury upon receipt of the x-ray results, the initial two-hour report to the state agency was not completed within the required timeframe. The Executive Director confirmed that the supervisor did not complete the initial two-hour report after being notified of the injury. The facility ultimately notified the state survey agency at 10:45 PM, which was outside the two-hour window from when the x-ray results were received and the injury was identified. This delay constituted a failure to comply with regulatory reporting guidelines for suspected abuse or injury of unknown source.