Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into injuries of unknown origin for one resident with advanced Alzheimer’s dementia, severe cognitive impairment, and who was nonverbal and bed/chair bound. The resident was observed with yellow bruising on the sternal chest wall and dark red-purple bruising on the rib cage, which were not consistent with the care provided and were not reported to the hospice provider or guardian. Photographs of the injuries were taken, but the anatomical locations were unclear, and staff could not consistently recall or identify the locations. Documentation was incomplete, with no clear record of how the injuries occurred, and there was no evidence that the family was notified about the bruising. Interviews revealed that staff did not follow up on the bruising after it was initially reported, and the abuse coordinator could not confirm who reported the incident or provide documentation of a thorough investigation, including staff interviews or education. The facility’s policy required immediate reporting, assessment, and comprehensive investigation of such incidents, including interviews and written statements from witnesses, but these steps were not followed. The nursing home administrator, who also served as the abuse coordinator, was unaware of the injuries until the survey and confirmed that a formal investigation and reporting to the state agency would have occurred had they been informed.