Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an alleged injury of unknown origin for a resident with multiple sclerosis and non-Alzheimer's dementia, who was rarely or never understood and required substantial assistance for daily activities. The resident developed a dark red bruise on her lower left leg, which was first noticed by her family and reported to an LPN. The family expressed concern that the bruise resembled handprints, and the LPN noted the family’s suspicion that the injury may have been caused by the Hoyer lift. The physician was notified, and an order to monitor symptoms was initiated. The DON later assessed the bruise and attributed it to the resident’s leg resting on the wheelchair pedals, implementing a new intervention to place a pillow for protection. However, the resident was unable to communicate how the injury occurred, and there was no documentation of interviews with staff or a formal investigation into the cause of the injury. Despite the facility’s policy requiring thorough investigation and timely reporting of all alleged violations, including injuries of unknown source, the DON did not report the incident as an injury of unknown origin. The DON confirmed during an interview that she did not follow the abuse policy and did not conduct or document interviews with staff regarding the incident. Additionally, staff were unaware of the new intervention to protect the resident’s legs, and there was a lack of communication regarding the incident and follow-up actions among the care team.