Failure to Report, Investigate, and Document Injury of Unknown Source
Penalty
Summary
The facility failed to follow its abuse policy regarding the reporting, investigation, and documentation of injuries of unknown source for one resident. A resident with moderate cognitive impairment and a recent history of hospitalization for a blood disorder and possible cancer was observed with significant bruising on the right side of her face and arms. The resident was unaware of the cause of the bruising, and her family member confirmed the presence of the bruising on previous days. Despite the facility's policy requiring documentation, investigation, and notification of the physician and representative for injuries of unknown source, there was no documentation of the facial bruising in the resident's medical record, nor was the incident logged in the facility's incident log. Staff interviews revealed that while an LPN was aware of the bruising and had notified the family, the Director of Nursing and the facility administrator were not informed of the injury. No investigation was conducted to determine the cause of the bruising, and the physician was not notified as required by policy. The lack of documentation, investigation, and appropriate notifications constituted a failure to adhere to the facility's established procedures for handling injuries of unknown source.