Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when a nurse aide discovered a bruise with red and purple discoloration on a resident's left hand while providing care. The resident, who had diagnoses of chronic obstructive pulmonary disease and vascular dementia and was documented as severely cognitively impaired, exhibited pain and would not allow the aide to touch the affected area. The nurse aide immediately reported the injury to the assigned LPN, who observed the bruise and attributed it to possible poor circulation. However, there was no documented evidence that the LPN reported this injury of unknown origin to facility administration as required by facility policy. Facility policy mandates that any incident or injury of unknown origin be reported immediately to a supervisor, who must then notify the administrator. The failure of the LPN to escalate the report of the resident's injury resulted in a delay in the facility being made aware of a potential abuse allegation. This lapse was confirmed during interviews with the Nursing Home Administrator and the Director of Nursing, who acknowledged that the required reporting procedures were not followed when the bruise was initially found.