CMS SOM App. J, Tag W153

as well as injuries of unknown source, are reported immediately to the administrator or to

other officials in accordance with State law through established procedures.

Guidance §483.420(d)(2)

Injuries of unknown source that give rise to a suspicion that they may be the result of abuse or

neglect, should be reported immediately.

An injury should be reported as an “injury of unknown source” when:

• The source of the injury was not witnessed by any person and the source of the injury

could not be explained by the client; and

• The injury raises suspicions of possible abuse or neglect because of the extent of the

injury or the location of the injury (e.g., the injury is located in an area not generally

vulnerable to trauma) or the number of injuries observed at one particular point in time

or the incidence of injuries over time.

It is important to note that members of the ICF/IID population are a mobile population and lead

active lives. Therefore, they experience normal day-to-day bumps and minor abrasions as they

go about their lives. These minor occurrences which are not of serious consequence to the

individual and do not present as a suspicious or repetitive injury (as discussed above) should be

recorded by the facility staff once they are aware of them and follow-up should be conducted as

indicated. For injuries that do not rise to the level of reportable “injuries of unknown source”,

the facility should follow its policies and procedures for incident recording, investigation, and

tracking.

The facility must immediately report any suspicious injuries of unknown source and all

allegations of mistreatment, neglect or abuse to a client residing in the facility regardless of who

is the alleged perpetrator (e.g., facility staff, parents, legal guardians, volunteer staff from

outside agencies serving the client, neighbors, or other clients, etc.).

If state law requires reporting to an agency or entity other than the administrator, the Centers

for Medicare & Medicaid Services (CMS) expects the administrator to be notified as well, in

order to ensure facility response to promptly safeguard the client(s).

For the purposes of this regulation “immediately” means there should be no delay between staff

awareness of the occurrence and reporting to the administrator or other officials in accordance

with State law unless the situation is unstable in which case reporting should occur as soon as

the safety of all clients is assured.