Failure to Investigate Bruise of Unknown Origin as Potential Abuse
Penalty
Summary
The facility failed to investigate a bruise of unknown origin as potential physical abuse for one resident with moderate cognitive deficits and a history of both receiving and exhibiting aggression. The resident was observed by the Assistant Director of Nurses to have a bruise above the left eye, which appeared to be in different stages of healing. When questioned, the resident was unable to recall the cause of the bruise, initially suggesting a possible fall but providing no details. The bruise was measured at 4 centimeters, and the nurse notified the resident's current nurse, who continued to monitor the situation. Despite the facility's policy requiring immediate reporting and investigation of suspicious bruises or injuries of unknown origin, the Director of Nurses advised that the bruise did not need to be reported to the Abuse Coordinator because it was under 7 centimeters in diameter. As a result, the incident was not reported or investigated as potential abuse at that time. The resident later reported that another resident had punched her on the forehead, which led to a retaliatory incident involving a pen, but this information was not initially known to the staff responsible for reporting. Interviews with staff confirmed that the decision not to report the bruise was based on its size and an assumption that it was caused by a fall, despite the resident's inability to recall the incident and the presence of a suspicious injury. The facility's failure to follow its own abuse prevention policy resulted in a lack of timely investigation into a possible case of resident-to-resident physical abuse.