Failure to Timely Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to timely investigate an injury of unknown origin for a resident with multiple complex diagnoses, including Alzheimer's disease, dementia with behavioral disturbances, conversion disorder with seizures, anxiety, depression, paranoid schizophrenia, and a nontraumatic intracerebral hemorrhage. Medical record review showed the resident was admitted with fragile skin and later developed a skin tear on the left elbow, as well as a bruise on the left lower arm. There was no documentation in the resident's record explaining how the skin tear or bruise occurred, nor was there evidence of an investigation into these injuries at the time they were discovered. Observation of the resident revealed a dressing on the left elbow, a dark purple bruise on the left lower arm, scratches on the upper arm, scabs above the dressing, and slight edema to the left arm. Interviews with facility staff confirmed that no investigation had been conducted to determine the cause of the injuries, and the facility's policy required timely identification and investigation of injuries of unknown origin. The lack of timely investigation and documentation regarding the injuries constituted non-compliance with facility policy and regulatory requirements.