Failure to Assess, Document, and Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to protect residents' rights to be free from abuse and neglect, as evidenced by the lack of assessment, documentation, investigation, and reporting of injuries of unknown origin for two cognitively impaired residents. One resident, with diagnoses including Paranoid Schizophrenia and Alzheimer's Disease, was found with multiple unexplained injuries over several days, including knots on the forehead, swelling and pain in the right hand, abrasions and bruising on the neck, and an open wound on the abdomen. Despite these findings, there was no timely documentation of falls, occurrence reports, or investigations into the causes of these injuries. Staff interviews revealed that the resident was frequently found on the floor, but this was considered part of his care plan, and no head-to-toe assessments or neuro-checks were performed after such incidents. Nurses and CNAs did not consistently notify each other or the physician about these events, and the DON was notified but did not initiate an investigation or report the injuries to state agencies. Another resident, also cognitively impaired, was documented with red scratches on the face, a knot and bruising on the head, and a swollen hand resulting in a finger fracture. Nursing staff failed to assess these injuries, document their origin, or notify the physician at the time of occurrence. No occurrence reports or investigations were completed for these injuries of unknown origin. The facility's own policy required staff to identify, document, and report all types of abuse and injuries of unknown origin, but this was not followed in these cases. Interviews with facility staff, including the Medical Director, LPNs, CNAs, and the DON, confirmed a lack of understanding and implementation of abuse and neglect reporting protocols. Staff admitted to not completing occurrence reports, not performing required assessments, and not notifying the physician or state agencies as required. The DON stated that she did not believe the injuries occurred at the facility and therefore did not initiate an investigation. The lack of documentation, assessment, and reporting placed all residents at risk and resulted in the facility being cited for Immediate Jeopardy at F-600.