Failure to Report and Assess Unexplained Facial Injury
Penalty
Summary
Facility staff failed to follow policies and procedures requiring immediate reporting and investigation of an unexplained injury when a resident was found with a swollen, darkly bruised left eye of unknown origin. The resident, who had diagnoses including Alzheimer's disease, anxiety disorder, major depressive disorder, and cognitive communication deficit, had a quarterly MDS showing severe cognitive impairment and a care plan identifying high fall risk and wandering behaviors, including entering others' rooms and non-compliance with wearing shoes and socks. On the date of the incident, the resident's wife visited around midday and discovered his black, swollen eye; staff told her they did not know what had happened and indicated there were no plans for any X-ray or further testing to assess the injury. A general progress note later documented that the resident's left eye was puffed and dark in color and stated they would continue to monitor, but no assessment of the injury was recorded in the clinical record. The DON, who was covering for the Administrator during a vacation period, reported that he was not informed of the resident's injury until two days after it was first noted, learning of it only during a morning meeting. He did not know who initially discovered the injury, whether it was nursing staff or the resident's spouse. Although a Risk Management assessment entry was made by the DON on that later date, no interviews or assessments related to the injury had been completed, and the incident was not reported to the proper personnel as required. The facility’s Incident/Accident Reporting policy defined unexplained injury as a situation where no incident is observed but the resident exhibits evidence of injury, and required prompt notification of the Administrator, DON, or department head on duty if abuse or neglect is suspected or there is a complaint of abuse or neglect. These required notifications and investigative steps were not carried out for this resident’s unexplained black eye.
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