Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an incident of injury of unknown origin for one resident. The resident, who had a diagnosis of dementia and neurocognitive disorder with severely impaired cognitive function, was observed to have a large, dark purple/red bruise on the left hip extending up the side. The bruise was first noticed by a medication aide, but was not reported until several days later, by which time it had increased in size and the resident was experiencing pain. There was no documentation of any falls, and the resident had a chair alarm in place. No SBAR was completed, and the APRN was not asked to assess the bruise during a facility visit. Interviews with staff confirmed that the Director of Nursing (DON) was aware of the bruise after it was reported but did not initiate an incident report or conduct an investigation. The DON stated that the resident frequently gets bruises and did not see the need to report or investigate this particular incident. This lack of action was in direct contradiction to the facility's policy, which requires that all injuries of unknown or suspicious origin be reported and investigated.