Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who had multiple medical conditions, including osteoarthritis, epilepsy, and anemia, and was at high risk for falls and skin impairment. Documentation showed that the resident had a fall, after which darker bruises were observed on her upper thighs, described as appearing to be from prior falls. However, subsequent skin checks and daily skilled notes did not document any new or existing bruises, and staff interviews revealed inconsistent awareness and reporting of the bruising. The resident was also noted to have additional bruising and skin tears on her forearm, which she attributed to a bracelet, and a significant bruise on her upper left hip that had been present for 10-14 days, but this was not documented or reported to nursing administration until brought to their attention during the survey. Interviews with staff, including LPNs and CNAs, indicated that while there were protocols for assessing and documenting falls and skin changes, these were not consistently followed. Staff were unaware of recent falls or new bruising, and weekly skin checks were not reliably performed or documented. The DON and RNC confirmed that the expected weekly skin sweeps were not being completed, and the nursing administration team was unaware of the new bruising on the resident's hip until it was pointed out during the survey. The facility's own policies required prompt notification and investigation of injuries of unknown source, as well as thorough documentation and communication with physicians and resident representatives, but these procedures were not followed in this case. The lack of timely investigation and reporting of the resident's bruising, as well as the failure to perform and document regular skin checks, resulted in a deficiency related to the facility's responsibility to identify, investigate, and report suspected abuse, neglect, or injuries of unknown origin. The facility's policies on change in condition and abuse prevention were not adhered to, leading to a delay in recognizing and addressing potential harm to the resident.