Failure to Report and Investigate Injuries of Unknown Origin
Penalty
Summary
Surveyors identified that the facility failed to report injuries of unknown origin to the state agency for two residents. For one resident with osteoarthritis, bipolar disorder, and dementia, bruising was observed on the hand and arm, and the resident reported the injury occurred during care. The incident was documented, and an internal investigation was conducted, but the investigation lacked proper documentation, including signed, dated, and timed statements. Staff statements did not address the presence or absence of bruises, and the investigation did not conclusively rule out abuse. Despite these gaps, the incident was not reported to the Department of Health as required by facility policy. For another resident with a history of cerebrovascular accident, non-Alzheimer's dementia, and muscle weakness, bruising was documented on both arms and the left hip. The resident was on a blood thinner and required significant assistance with daily activities. Although the care plan required regular skin checks, there was no evidence that an investigation was initiated or that an Accident/Incident Report was completed for the bruising. The nurse did not report the bruises, and the required investigation and notification to the Department of Health did not occur. Interviews with facility leadership confirmed that the required steps for investigating and reporting injuries of unknown origin were not followed in both cases. The Director of Nursing and Assistant Director of Nursing acknowledged that investigations were incomplete and that the incidents were not reported to the state agency, contrary to facility policy and regulatory requirements.