Failure to Immediately Investigate Injuries of Unknown Source
Penalty
Summary
The facility failed to immediately investigate injuries of unknown source in accordance with its abuse prohibition policy for two residents. One resident with Alzheimer's and Parkinson's disease, who was dependent for transfers and had moderate cognitive impairment, was found with a bruise of unknown origin on the right breast. There was no documentation in the resident's record or incident reports regarding how or when the bruise occurred, nor evidence that staff interviews were conducted. Another resident with heart failure, diabetes mellitus, and atrial fibrillation, who was dependent with toileting hygiene and transfers and had intact cognition, was found with a dark bruise near the rectum. The resident attributed the bruise to a recent bowel movement and denied abuse or pain, but again, there was no further information or staff interviews documented in the records or incident reports. During an interview, the DON confirmed that bruises found on the breast or anal region are considered suspicious for abuse and should trigger an immediate investigation, which did not occur in these cases. The facility's policy requires that all reports of abuse, including injuries of unknown source, be promptly and thoroughly investigated, with results documented. The policy specifically lists bruising in areas such as the inner thigh, chest, face, and breast, or bruises of unusual size or in atypical locations, as requiring immediate investigation to rule out abuse. Despite these requirements, investigations were not initiated for either resident after their injuries were discovered.