Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report and investigate an injury of unknown origin for one resident who was observed with multiple large and small reddish/purple bruises and purpura on her bilateral forearms and right hand. The resident, who has severe cognitive impairment, dementia, stage 4 chronic kidney disease, hypertension, and dysphagia, was noted to be dependent on staff for bed mobility and had limitations in range of motion. Progress notes indicated that a nurse discovered a bruise on the resident's lower left arm and that the resident complained of shoulder pain, prompting an x-ray. The x-ray revealed degenerative changes and possible anterior subluxation of the shoulder, but no recent fracture. Despite these findings, there was no facility investigation into the cause of the injury to the resident's right shoulder. Interviews with facility staff confirmed that no investigation was conducted regarding the bruising or shoulder injury. The administrator and DON stated that the bruising was attributed to the resident lying in bed with her arms pressed against the bed rail, and that the shoulder pain and subsequent x-ray findings were considered to be related to degenerative changes. The facility's abuse policy requires an internal investigation and reporting to authorities for injuries of unknown source, but this process was not followed in this case.