Failure to Investigate and Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to initiate an investigation into an alleged violation of abuse, specifically regarding injuries of unknown origin for one resident. On 5/19/25, a resident with severe cognitive impairment, muscle weakness, osteoarthritis, thrombocytopenia, dementia, and protein-calorie malnutrition was found to have bruising and open skin areas on both upper extremities. Certified Nursing Assistants reported these injuries to a nurse while providing care, but no incident report or investigation was initiated at that time. Subsequent interviews with facility staff, including the Unit Manager, DON, and Administrator, confirmed that the injuries were of unknown origin and should have triggered an immediate investigation and reporting process as per facility policy. However, the facility did not begin any investigation or report the incident to the state agency until prompted by surveyors, and no documentation of an initial investigation was available for the injuries observed. This failure to act left the resident unprotected from further potential abuse or mistreatment while the investigation was pending.