Failure to Timely Report Investigative Findings for Resident Injuries
Penalty
Summary
Facility staff failed to report investigative findings for reportable events within the required timeframe for two residents who sustained injuries of unknown origin. In the first case, a resident developed a hematoma on the left lower extremity, and although the incident was initially reported to the State Survey Agency, the investigative findings were not submitted until two days after the deadline. In the second case, another resident experienced swelling and bruising to the right hand, and the investigative findings were also reported two days late. Staff member A, responsible for submitting these reports, stated that in both instances he mistakenly pressed the save button instead of the send button in the reporting system and did not realize the error until after the deadline had passed. Additionally, for the second incident, staff member A expressed uncertainty about whether the event should have been reported but ultimately did so as an unknown injury.