Failure to Investigate Injury of Unknown Origin
Penalty
Summary
A deficiency was identified when the facility failed to conduct an investigation into an injury of unknown origin for a resident with severe cognitive impairment and multiple medical conditions, including a history of cerebrovascular accident, non-Alzheimer's dementia, and muscle weakness. The resident was dependent on staff for most activities of daily living and was prescribed a blood thinner. Documentation showed that the resident had bruising on both arms and a small area on the left hip, but there was no evidence that an investigation was initiated or completed regarding these findings. Interviews revealed that the LPN who observed the skin discolorations did not consider them to be bruises and chose not to report or document the findings to a supervisor, despite annual in-services on accident/incident and abuse protocols. The RN Supervisor confirmed that any bruises of unknown origin, especially in cognitively impaired residents, should have been reported and investigated, with notification to the physician and family. The DON also stated that the nurse should have initiated an investigation and informed the appropriate parties, which did not occur in this case.