Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate and report an injury of unknown origin for a resident who was dependent on staff for all activities of daily living. The resident was found with a discolored and swollen forehead, and later developed bruising under her left eye and on her right hand. Documentation showed that the resident stated she had fallen and was picked up off the floor, but could not recall who assisted her. A nurse aide observed bruising during a shower but did not report it immediately, only notifying the LPN after the bruising worsened the next morning. The facility's policy required immediate assessment, notification, and investigation of such injuries, including prompt reporting to the Department of Health if abuse or neglect was suspected. Despite these requirements, the facility did not ensure timely reporting or a thorough investigation to rule out neglect or prevent further injuries. The DON confirmed that staff are expected to report all injuries of unknown origin at the time of identification, but this did not occur in this case. The failure to follow policy resulted in a lack of appropriate investigation and reporting to the necessary authorities regarding the resident's injuries.