Failure to Investigate and Report Unexplained Bruising
Penalty
Summary
The facility failed to thoroughly investigate and report unexplained bruising found on a resident who was severely cognitively impaired and taking anticoagulant and antiplatelet medications. The resident was observed with multiple dark purplish bruises on both arms, extending from the knuckles to the upper arms, and was unable to explain the cause of the bruising. Staff interviews confirmed that the resident was known to bruise easily, and protective arm sleeves were used as an intervention. However, there was no evidence that an incident report was completed, nor was there documentation of timely notification to the Director of Nursing (DON) or the resident's physician regarding the bruising as required by facility policy. Record reviews showed that the resident had a history of multiple bruises documented during weekly skin assessments, but these findings were not escalated for further investigation. The DON confirmed that staff should have reported the bruising, completed an incident report, and notified the physician. The facility's policy requires that any unexplained injury, especially when the source is unknown or the resident cannot explain it, must be identified, investigated, and reported as a potential case of abuse or neglect. Despite the presence of multiple bruises over time and the resident's inability to provide an explanation, the facility did not initiate a thorough investigation or report the findings to the state survey agency within the required five working days. This lack of action was contrary to both facility policy and regulatory requirements, resulting in a deficiency for failing to respond appropriately to alleged violations of abuse, neglect, or mistreatment.