Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an allegation of injury of unknown origin for one resident with significant medical history, including long-term anticoagulant use, cognitive impairment, and a colostomy. The resident was re-admitted to the facility with documented bruising on her arms and legs, but there was no documentation in the care plan or progress notes regarding bruising or bleeding in the vaginal, groin, or perineal areas. Hospital records and interviews with the emergency room nurse indicated that the resident was found with bleeding and bruising in these sensitive areas, which was communicated to the facility nurse at the time of hospitalization. Despite this notification, the facility staff did not document or report the new findings of vaginal and perineal bruising and bleeding. The nurse in charge at the time of the incident acknowledged being informed by the hospital but did not immediately notify the Director of Nursing or the Administrator, as required by facility policy. The Director of Nursing and Administrator both stated they were not made aware of the hospital's findings regarding the vaginal injuries, and no investigation was initiated into the injury of unknown origin. Facility policy requires immediate reporting and investigation of any alleged abuse or injury of unknown source, especially when the resident cannot explain the injury and the location is suspicious. In this case, the lack of timely reporting and investigation by staff resulted in a failure to respond appropriately to an allegation of potential abuse or injury of unknown origin, as required by both facility policy and regulatory standards.