Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report and submit a completed investigation of an injury of unknown origin for one resident to the State Agency within the required five working days. According to the facility's own policy, any injury of unknown or suspicious origin, including bruises that are not easily explained, must be reported and investigated. In this case, a large, bruised area was first noticed by a Medication Aide on the resident's left side, radiating into the waist area and under the left breast. The bruise increased in size and became painful, yet there was no documentation of a fall or incident that could explain the injury. The resident had a chair alarm in place and was variably assisted with ambulation and transfers, but no SBAR was completed, and the Advanced Practice Registered Nurse was not asked to assess the bruise when present in the facility. Interviews revealed that the Director of Nursing became aware of the bruise after it was reported several days later but did not initiate an incident report or investigation. The DON stated that the resident frequently gets bruises and did not feel it was necessary to report or investigate this particular bruise. As a result, the required incident report and investigation were not completed or submitted to the State Agency within the mandated timeframe, constituting a failure to comply with both facility policy and state regulations.