Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and did not establish or follow policies and procedures to report and investigate such allegations for one resident. A resident with severe cognitive impairment, dementia, diabetes, and depression was found with bruising and a skin tear on her left arm. The incident was first reported by a family member to a nurse, who documented the injuries and provided first aid, but did not initiate a full investigation or complete all required notifications and documentation as outlined in facility policy. Subsequent record reviews showed that there were no physician orders for monitoring or treating the injuries, and no skin assessment was completed after the injuries were noted. The resident's care plan was not updated to reflect the new injuries, and there was no incident report or evidence of an internal investigation. Interviews with nursing staff revealed inconsistent understanding and application of the facility's abuse and injury reporting protocols, with some staff unaware of the incident and others unsure of the required steps for reporting and investigation. The Director of Nursing and Administrator were either unaware of the incident or did not recall it, and the required internal investigation and reporting to the state agency did not occur. The facility's own Abuse Prohibition Policy required prompt investigation and reporting of injuries of unknown origin, but this was not followed in this case, resulting in a failure to protect the resident and ensure proper oversight and response to potential abuse or neglect.