Incomplete Investigation of Bruise of Unknown Origin
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into a bruise of unknown origin found on a resident. The facility's policy requires that all allegations be thoroughly investigated, including reviewing documentation, medical records, and interviewing all relevant staff members who had contact with the resident during the period in question. In this case, a nurse aide discovered a dark purple bruise on the back of the resident's head, which caused mild pain when touched. The resident had multiple diagnoses, including cerebral infarction, anxiety, depression, dementia, hypertension, and diabetes. During the investigation, statements were collected from various staff members who worked on the relevant shifts, but the nurse aide who was assigned to the resident on the day prior to the discovery of the bruise was not interviewed. This omission was confirmed by the Assistant Director of Nursing. The failure to interview all pertinent staff, as required by facility policy, resulted in an incomplete investigation of the incident.