Failure to Investigate and Report Facial Bruise of Unknown Origin
Penalty
Summary
The provider failed to ensure a thorough investigation and timely reporting to the South Dakota Department of Health regarding a facial bruise of unknown origin for a resident. The incident began when the resident was found unresponsive in the activity room, with a weak pulse and low blood pressure, and was subsequently transported to the emergency room. A drug screen revealed the presence of a benzodiazepine, which was not prescribed to the resident. The initial facility-reported incident did not mention any injuries or bruises. Subsequent observations and record reviews identified a bruise on the resident's forehead, which was not documented in the initial report or in skin assessments completed after the incident. Multiple staff members noticed the bruise at different times, but there was confusion and lack of clarity regarding when and to whom the bruise was reported. The director of nursing was not aware of the bruise, and there was no evidence that an investigation was conducted to determine its cause. Documentation of shift reports and communication about the injury was also lacking. The facility's policies require immediate reporting and thorough investigation of any suspected abuse, injury of unknown source, or unusual injuries, including prompt notification of management and documentation of findings. In this case, these procedures were not followed, as there was no documented investigation or timely notification to facility leadership or the state agency regarding the resident's facial bruise.