Failure to Thoroughly Investigate Allegation of Abuse and Unexplained Bruising
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was found with multiple facial bruises. The resident, who had diagnoses of generalized muscle weakness and depression and lacked decision-making capacity, was discovered with significant discoloration on both cheeks, jawline, temple, and orbital area. A CNA reported that the resident alleged being hurt by an RN and submitted a written statement to the Director of Staff Development (DSD). However, the DSD did not review the statements and only passed them to the Director of Nursing (DON). The DON acknowledged that the investigation into the resident's bruises was incomplete. Although statements were collected from staff assigned to the resident, the DON did not interview the CNA who reported the allegation and did not have her statement. The facility's policy required extensive efforts in investigating unusual occurrences or injuries of unknown origin, but these procedures were not fully followed in this case.