Failure to Investigate Injury of Unknown Source to Resident’s Hand
Penalty
Summary
The facility failed to investigate an injury of unknown source when a resident developed yellowish‑purplish discoloration and later ecchymosis on the dorsal (back) surface of the left hand. The resident, who had COPD, generalized muscle weakness, moderate cognitive impairment, and was dependent on staff for ADLs and bed mobility, was originally admitted and later readmitted to the facility. Review of progress notes from 1/21/2026 to 1/23/2026 showed no documentation that the discoloration noted on 1/21/2026 or the ecchymosis noted on 1/23/2026 were investigated. During observation and interview on 1/23/2026, the resident had yellowish‑purplish discoloration on the left dorsal hand and stated it happened after someone took her blood pressure too tightly on that hand, but could not recall when. A CNA reported observing the same yellowish‑purplish discoloration on the resident’s left dorsal hand on 1/21/2026 and stated she notified an LVN at that time. The Treatment LVN reported that on 1/23/2026 the wound MD saw ecchymosis on the resident’s left dorsal hand. The LVN interviewed later stated that when staff report discoloration on a resident’s skin, the LVN should notify the DON and Administrator for investigation due to the possibility of abuse. The DON stated that when staff see skin discolorations, the charge nurse should assess the resident, ask how it happened, complete a change of condition assessment, and notify the MD, and that injuries of unknown origin must be investigated and reported to CDPH. The Administrator stated he was not aware of the unexplained bruising and described that an injury of unknown origin requires investigation and may need to be reported to CDPH if determined to be alleged abuse. The facility’s Abuse Prevention and Management policy defined injury of unknown source and required the Administrator or designee to immediately initiate an investigation upon receiving such a report; however, no such investigation was documented for this resident’s hand injury.
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