Failure to Timely Report 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 timeframe. According to the facility's Abuse Prevention Policy, all alleged violations involving abuse, neglect, exploitation, mistreatment, or injuries of unknown source must be reported immediately, but no later than two hours after the allegation is made, especially if the event involves abuse or results in serious bodily injury. In this case, a resident was transported from the facility to a dialysis center without any apparent injury. While at the dialysis center, the resident developed a hematoma to the head that was bleeding profusely and was subsequently sent to the emergency room, where a CT scan revealed a subarachnoid hemorrhage. The resident received care in the emergency room and was later pronounced deceased. The facility received notification of the incident after the resident was sent to the emergency room. The Administrator was informed by the Coroner of the resident's death and the nature of the injuries later that evening. The initial report to the SSA was not submitted until after the Administrator received this information, which was outside the required reporting timeframe. The facility's final investigative summary concluded that there was no substantiated evidence that the injury occurred at the facility, but the delay in reporting the incident to the SSA constituted a failure to comply with the facility's own policy and regulatory requirements.