Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source for a resident with severe cognitive impairment and multiple physical dependencies. The resident, who had diagnoses including Parkinson's disease, dementia, and anxiety, was non-ambulatory, required substantial to maximal assistance with all activities of daily living, and was unable to communicate about her safety or the cause of her injuries. On assessment, staff identified multiple bruises of varying sizes and colors on the resident's inner thighs and knees, which were described as fingerprint-sized and arranged in a straight line. The resident's care plan directed staff to use caution during transfers and to monitor and report any suspected abuse or neglect, but the source of the bruising was not observed, and the resident could not explain the injuries. The facility's documentation and investigation into the incident were incomplete. Progress notes indicated that the resource manager was notified and the resident's family was informed, but did not specify what actions were taken. The state agency report and facility records showed that previous skin assessments did not note any discoloration or bruising, and that the bruising could have been related to the process of changing the resident's brief. However, there was no evidence that staff interviews included questions about possible abuse, aggressive care, or suspicious behavior by staff or other residents. Staff who discovered or observed the bruising confirmed they were not interviewed about abuse or the incident itself. Interviews with facility leadership and the medical director confirmed that the investigation did not follow policy requirements for injuries of unknown origin, which called for comprehensive interviews with all staff who had contact with the resident during the relevant period, including questions about abuse. The director of nursing acknowledged that staff were only asked about skin changes, difficulties with repositioning, and care challenges, and not about abuse. The medical director stated that he was not notified of the incident and would have expected a more thorough investigation, including an examination to determine if the injuries were suspicious.