Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident to the State Survey Agency (SSA) within the required two-hour timeframe. The incident occurred when a resident, who had a history of intertrochanteric femur fracture, arterial aneurysm, and rheumatoid arthritis, was found by staff in the early morning hours with a bleeding wound on the right posterior scalp. The resident was visibly distressed, in severe pain, and unable to explain the cause of the injury. Staff observed a large pool of blood on the floor, the resident's walker overturned, and the resident using her bedside table for support. The resident was transferred to an acute care hospital, where she was diagnosed with trace pneumocephalus, subarachnoid hemorrhage, and subdural hematoma, and admitted to the ICU for further monitoring. Interviews with facility staff revealed that the injury was discovered at approximately 3 a.m., but the SSA was not notified until 4:38 p.m., more than twelve hours after the incident. The facility's policy requires that injuries of unknown origin, especially those resulting in serious bodily injury, be reported to the SSA, Ombudsman, and law enforcement within two hours. Staff acknowledged awareness of this policy and the reporting requirements, but the notification was delayed significantly beyond the mandated timeframe. Record reviews confirmed the timeline of events, including the initial discovery of the injury, the resident's transfer to the hospital, and the late reporting to authorities. Documentation showed that the required SOC 341 form was sent to the appropriate agencies and law enforcement was notified, but only after a substantial delay. The failure to report the injury promptly constituted a breach of the facility's own policy and regulatory requirements regarding timely reporting of suspected abuse, neglect, or injuries of unknown origin.