Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for one resident who was found with scattered bruising on her inner thighs. Nursing staff documented the bruising, noting the resident was a standby assist for toileting and sometimes refused care. The resident attributed the bruising to her incontinence briefs, and no pain or discomfort was noted. Despite the presence of unexplained bruising in an unusual location, the facility did not report the incident to the Illinois Department of Public Health (IDPH) as required. The administrator acknowledged that the bruises were investigated only by interviewing staff and not other residents, which was inconsistent with facility policy that requires interviewing all involved persons, including residents, when investigating injuries of unknown origin. The resident involved had multiple diagnoses, including Alzheimer's disease, dementia with behavioral disturbance, diabetes, vitamin B deficiency, and was on hospice care. The administrator reviewed hospital records and noted that the bruising appeared different on subsequent days and that the resident later died, possibly from an aortic dissection or aneurysm, which could explain the bruising. However, the facility's investigation did not include interviews with other residents who might have had relevant information, as required by their own policies on unexplained injuries and abuse investigations.