Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown source as required by federal and state regulations. A resident with a history of severe cognitive impairment, osteoporosis, osteopenia, and other chronic conditions complained of right arm pain. An X-ray revealed a non-displaced fracture of the right proximal humeral shaft, but the resident was unable to explain how the injury occurred, and there was no evidence of a fall or trauma. The incident was classified as an injury of unknown source. According to facility policy and regulatory requirements, all alleged violations involving abuse, neglect, or injuries of unknown source that result in serious bodily injury must be reported to the New York State Department of Health within two hours of discovery. In this case, the X-ray result confirming the fracture was obtained, but the facility did not report the incident to the Department of Health within the required two-hour timeframe. Instead, the report was submitted more than a day later. Interviews with facility leadership revealed that the delay in reporting was due to their determination that the injury was not the result of abuse or a crime, and that the fracture could be attributed to the resident's underlying medical conditions. Despite this, the regulations require prompt reporting of injuries of unknown source, regardless of suspected cause, when serious bodily injury is involved. The deficiency was identified based on observation, record review, and staff interviews.