Failure to Timely Report and Investigate Bruises of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting and investigation of a bruise of unknown origin for one resident, as required by policy. The resident, who had multiple diagnoses including bipolar disorder, psychotic disorder with delusions, schizophrenia, and was on a blood thinner (Eliquis), was observed with bruises on both upper arms and a large purplish red bruise under the left breast. Initial observations and interviews revealed that staff, including LPNs and CNAs, were either unaware of the bruising or had not reported it according to protocol. The resident denied any abuse or pain and declined a full skin assessment initially, but later allowed for further examination, which confirmed the presence of the bruises. Despite the facility's policy requiring immediate investigation and reporting of suspected abuse or unexplained injuries, the bruises were not promptly reported or investigated. The DON confirmed that an investigation and report to the State Agency were only initiated after the issue was brought to their attention, and could not explain the delay or the lack of documentation in prior skin assessments. The facility's policy mandates reporting all alleged violations within specified timeframes, particularly for injuries of unknown origin or those in potential areas of abuse, such as the breast, but these procedures were not followed in this instance.