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 a resident with multiple medical diagnoses, including severe cognitive impairment, diabetes, and heart failure. The resident was found to have a large, dark purple bruise on the left lower abdomen, which was not present during a prior skin assessment and was first observed by a CNA, who reported it to an LPN. The bruise was subsequently reported to the DON and the physician, but the resident was unable to explain the cause of the injury, and no fall or other incident was noted. Documentation showed that insulin had been administered in the same area, but this information, along with shower sheets and daily skin assessments, was not reviewed as part of the investigation. Interviews with staff confirmed that the investigation did not adequately consider all relevant information or rule out abuse as a possible cause of the injury. The DON acknowledged that the investigation was incomplete, and the administrator confirmed that important records were not reviewed to determine the etiology of the bruise. The facility's abuse policy defines injuries of unknown source and outlines the need for thorough investigation, which was not followed in this case.