Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate an allegation of abuse and neglect for one resident out of a sample of six, specifically not completing thorough and timely investigations when the resident sustained injuries of unknown origin. According to the facility's abuse policy, any suspicion of abuse, neglect, or injury of unknown source must be reported immediately and investigated, including interviews with relevant staff, residents, or family members. However, documentation showed that bruising and discoloration on the resident's forearms were noted in nursing records, but there was no evidence that these injuries were investigated or that their origin was determined. The resident involved was over 65 years old, diagnosed with Alzheimer's disease with late onset, severe dementia with agitation, lack of coordination, and anxiety disorder. The resident required staff assistance with most activities of daily living and had care plans in place for dementia, ADL support, and skin care, which directed staff to observe and report any skin changes such as bruises or cuts. Despite these directives, nursing documentation on two separate occasions identified bruising and discoloration on the resident's arms, but there was no follow-up to determine the cause or to rule out abuse, as required by facility policy. Interviews with the NHA and DON revealed that they were unaware of the documented bruising and that no investigation had been initiated at the time the injuries were first observed. The NHA acknowledged that bruises and injuries of unknown origin should have been investigated and that she should have been notified to start an investigation. The lack of documentation and investigation into the origin of the bruising constituted a failure to respond appropriately to alleged violations, as required by the facility's own policies.