Failure to Timely Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to immediately report injuries of unknown origin to the administrator and did not notify the State Agency (SA) within the required reporting guidelines for two residents. One resident with Alzheimer's and Parkinson's disease, who was dependent for transfers and had moderate cognitive impairment, was found to have a bruise on the right breast of unknown origin. The LPN who discovered the bruise believed it was caused by a sit-to-stand lift and, since the resident denied abuse, did not report the injury to the administrator immediately, instead sending an email notification several hours later. The bruise was not investigated or reported to the SA as required. Another resident, with diagnoses including heart failure, diabetes mellitus, and atrial fibrillation, and who was dependent with toileting and transfers, was found to have a dark bruise near the anal region. The LPN who identified the bruise did not notify the DON or administrator immediately, as the resident believed the bruise was from a bowel movement and denied abuse. Notification to administration was delayed and sent via email at a later time. The facility's policy required that allegations involving abuse be reported no later than two hours after the allegation is made, but this protocol was not followed in either case.