Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential resident abuse for a resident who was found to have an injury of unknown origin. The resident, who was severely cognitively impaired and dependent on staff for most activities of daily living, developed significant bruising and right hip pain over several days. Despite multiple observations and documentation of pain and bruising by nursing staff, there was a delay in reporting the injury to the appropriate authorities and in initiating an investigation into the cause of the bruising. Staff interviews revealed that bruising was observed and reported to nurses, but the injury was not measured, and documentation was incomplete. The resident's pain increased, and the bruising expanded before the incident was reported to the state and an investigation was started. The resident's medical history included atrial fibrillation, dementia, arthritis, and use of an anticoagulant, which increased the risk of bruising. Staff documented ongoing pain and bruising, with the resident at times unable to recall how the injury occurred. Despite these findings, there was a lack of timely communication with the medical provider, and the director of nursing was not notified promptly when the bruising and pain worsened. The facility's policy required immediate investigation and reporting of suspected abuse or unexplained injuries, but this was not followed in this case. Interviews with staff and the medical director confirmed that the resident's cognitive impairment made it difficult to obtain an accurate history, but staff were expected to report and investigate unexplained injuries immediately. The delay in reporting, incomplete documentation, and failure to initiate an immediate investigation resulted in a deficiency related to the facility's response to an alleged violation and potential abuse.