Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source to the State Survey Agency (SSA) within the required two-hour timeframe after discovery. Specifically, a resident with vascular dementia, severe cognitive impairment, and hemiplegia was found to have a supracondylar fracture of the femur after complaining of knee pain. The injury was discovered when an x-ray report was received, and the resident was subsequently sent to the emergency department for treatment. The facility's policy requires that such incidents, when involving serious bodily injury and of unknown source, be reported to the SSA within two hours. However, the initial report to the SSA was not submitted until nearly 24 hours after the injury was discovered. The Administrator stated that the delay occurred because she mistakenly believed the incident was a fall, which would have allowed for a longer reporting window, rather than an injury of unknown source. There was no evidence of a witnessed fall or incident, and the resident's care plan and follow-up documentation confirmed the injury was of unknown origin.