Failure to Investigate and Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to implement its written policies and procedures regarding the investigation and reporting of potential abuse, neglect, and injuries of unknown origin for one resident. The resident, who had severe cognitive impairment, muscle weakness, osteoarthritis, thrombocytopenia, dementia, and protein-calorie malnutrition, was observed to have bruising and open areas on both upper extremities. Certified Nursing Assistants (CNAs) reported these findings to a nurse the previous day, but the nurse did not document or report the injuries, nor was a skin assessment performed at that time. Interviews with facility staff revealed that the Unit Manager and Director of Nursing (DON) were unaware of the injuries until the day after they were first observed by the CNAs. The DON and Administrator both acknowledged that the injuries were of unknown origin and should have been immediately investigated and reported according to facility policy. The nurse who first observed the injuries admitted to not reporting or documenting them, stating uncertainty about whether the injuries were new. No initial investigation was conducted into the injuries reported the previous day, and there was no documentation or evidence of an internal investigation related to the bruising and open skin areas. Additionally, a review of the Health Care Facility Report System showed that the incident had not been reported to the state agency as required. The facility's failure to follow its own policies resulted in a lack of timely investigation and reporting of potential abuse or neglect.