Failure to Investigate and Document Bruises of Unknown Origin
Penalty
Summary
The provider failed to thoroughly investigate bruises of unknown origin for a cognitively impaired resident who required assistance with all activities of daily living. Over several weekly skin assessments, multiple bruises and areas of discoloration were documented on the resident's arms, knees, thighs, and forearms. These assessments lacked measurements, clear descriptions, and did not identify the cause or potential cause of the bruises. Additionally, there was no documentation of interventions to prevent further bruising, and the care plan did not reflect a history or risk of frequent bruising for the resident. Nursing staff did not complete required Incidence/Variance reports for the bruises of unknown origin, which would have triggered an investigation to determine the root cause, rule out abuse or neglect, and develop preventive interventions. The facility's policy required such reports for unexplained bruises, but this process was not followed. Interviews with supervisory staff confirmed that the expected procedures for assessment and reporting were not adhered to, and that the documentation in the electronic medical record was incomplete regarding the nature and management of the resident's skin injuries.