02/26/2026
Survey Tip of the Week: Injury of Unknown Source
Recent survey activity has included citations related to failure to properly identify and report injuries of unknown source. Under the Long-Term Care Survey Process (LTCSP), surveyors are instructed to observe residents for signs of injury and determine whether those injuries warrant further investigation, including medical record review and evaluation of facility reporting practices. Facilities must ensure staff understand when an injury meets the regulatory definition of “injury of unknown source” and when reporting requirements are triggered.
According to the State Operations Manual (SOM) Appendix PP, an injury must be classified as an “injury of unknown source” when all three criteria are met: the source of the injury was not observed by any person; the source of the injury could not be explained by the resident; and the injury is suspicious based on its extent, location, number, or pattern over time. Suspicion may arise when an injury is located in an area not generally vulnerable to trauma, when multiple injuries are discovered at one time, or when injuries appear to have occurred over a period of time. Facilities are expected to promptly assess newly discovered injuries to determine whether they meet this definition and whether they rise to the level of an alleged violation requiring reporting.
Examples of injuries that commonly require reporting when unobserved or unexplained include fractures, sprains, dislocations, burns, blisters, bite marks, suspicious bruising to the head, neck, chest, or back, unexplained swelling, lacerations, patterned bruising suggestive of hand or object marks, bilateral bruising (including inner thighs), wrap-around bruising, facial injuries such as black eyes or oral trauma, injuries to the genital area or breasts, and any unexplained injury requiring hospital transfer. Even when an injury is explained, if it appears to be the result of abuse, it must still be reported.
Not every injury requires reporting. Bruising associated with recent lab draws, clearly explained injuries without additional indicators of abuse or neglect, and witnessed injuries without suspicious circumstances may not meet the reporting threshold. However, facilities must still assess and monitor the resident, notify the physician and resident representative as appropriate, and thoroughly document the injury and any investigation in the medical record.
Facilities should also remember that if there is a reasonable suspicion of a crime related to the injury, covered individuals must report to the State Survey Agency and law enforcement within required timeframes under F609. Reviewing your abuse prevention policy, retraining staff on the three required criteria, and auditing recent incident reports for proper classification and timeliness can help ensure compliance and protect residents from harm.
