Failure to Investigate Bruise of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation following the discovery of a bruise of unknown origin on one of three residents reviewed for bruises. According to the facility's Abuse and Neglect Policy, any injury of unknown source should be promptly and thoroughly investigated, including reviewing the resident's medical record, interviewing relevant staff, witnesses, the resident (if appropriate), and documenting the results. In this case, a large circular red/purple bruise was observed on a resident's left mid back by an LPN during a transfer to a stretcher. The LPN reported the bruise to the Director of Nursing (DON), noting that the resident was on Eliquis, a blood thinner that had been placed on hold, and that there were no recent falls other than one that occurred two to three weeks prior. The LPN stated the bruise appeared overnight and could not be explained. Despite the policy requirements and the report made to the DON, no investigation was initiated or documented regarding the bruise of unknown origin. Both the DON and the facility Administrator confirmed that an investigation should have been started but was not. The lack of investigation meant that the facility did not follow its own policy for responding to injuries of unknown origin, as required for potential abuse or neglect cases.