Failure to Timely Report and Investigate Unexplained Bruising
Penalty
Summary
A resident with a history of sepsis, cognitive decline, atherosclerotic heart disease, and dementia was noted to have multiple bruises on her upper and lower extremities over several weeks. The resident was on anticoagulant and antiplatelet therapy, and her care plan included specific interventions to monitor and report signs of bleeding or bruising. Despite repeated documentation of bruising in weekly skin assessments, there was no evidence that these findings were promptly reported to the charge nurse, physician, or Director of Nursing (DON) as required by facility policy. The resident herself was unable to explain the origin of the bruises, and staff interviews confirmed that the bruising was known but not recently reported to appropriate authorities. Facility policy mandates that injuries of unknown source, especially those that are unexplained by the resident and are suspicious due to their extent or location, must be identified, investigated, and reported to the DON, administrator, state, and/or adult protective services. In this case, the LVN acknowledged not reporting the bruises, and the DON confirmed that an incident report should have been completed and notifications made. The failure to report and investigate the bruising as potential abuse, neglect, or injury of unknown source constitutes a deficiency in timely reporting and investigation as required by regulation and facility policy.