Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The provider failed to ensure that an investigation was completed and documented for a resident who developed significant bruising and swelling to her left hand and forearm of unknown origin. The resident, who had a history of hemiplegia due to stroke, dysphagia, congestive heart failure, anxiety, and insomnia, was noted by her family to have no visible injuries during a visit, but upon their return a few days later, they observed extensive bruising and swelling. Digital photographs confirmed the presence of purple and black bruising extending from the fingers to the forearm. The injury was first documented by the medical provider, who noted the resident was unable to recall the cause, and staff speculated about possible causes, including a blood draw, which was later ruled out as it was performed on the opposite arm. Despite the identification of the injury, there was no documentation to support that an investigation had been initiated to determine the cause or contributing factors. The LPN who first documented the injury did not report it to a nurse supervisor, and as a result, no investigation was started. The facility's policy required that injuries of unknown origin be promptly reported and thoroughly investigated, but this process was not followed in this case. Interviews with staff, including the LPN, physical therapist, infection preventionist, and administrator, confirmed that the required procedures for reporting and investigating injuries of unknown origin were not adhered to. The lack of investigation meant that no actions were taken to prevent recurrence, and the provider's own policy for abuse and neglect, which mandates prompt reporting and investigation of such events, was not implemented.