Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to 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 mild degenerative arthritic changes and possible anterior subluxation of the humeral head, but no recent fracture. Despite these findings and the facility's abuse policy requiring an internal investigation for injuries of unknown source, no investigation was conducted into the resident's right shoulder injury. The administrator and DON stated that the bruising was attributed to the resident lying with her arms against the bedrail and that the shoulder pain and subsequent x-ray occurred afterward. However, there was no documentation of an investigation to determine the source of the injury, as required by facility policy.