F0609

E

Failure to Report Injury of Unknown Origin Within Required Timeframe

Rayville, Louisiana Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an injury of unknown origin to the State Agency within the required 24-hour timeframe. Facility policies on incidents/accidents and on abuse, neglect, and exploitation require that injuries of unknown origin be treated as reportable events, with written procedures for identifying, investigating, and reporting such occurrences. The abuse policy specifies that all alleged violations, including injuries of unknown origin, must be reported to the Administrator and appropriate state agencies within specified timeframes, including not later than 24 hours if the events do not involve abuse or serious bodily injury.

Resident #55, who had diagnoses including chronic diastolic congestive heart failure, atrial fibrillation, dementia, cognitive communication deficit, rheumatoid arthritis, and a history of malignant neoplasm of the right breast, was identified as having a large bruise on the right shoulder/armpit area. The resident’s quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and documented dependence on staff for all ADLs, including substantial/maximal assistance with rolling in bed and dependence for transfers. On observation, the resident was unable to state how the bruise occurred, and a CNA reported that the bruise had been present for several weeks without a known cause. The resident was also receiving Eliquis 2.5 mg twice daily.

Nursing documentation dated 12/04/2025 showed that the treatment nurse was notified by a hospice CNA of a new large bruise under the resident’s right armpit, measuring 7 cm by 3 cm with a light purple tint. The resident denied pain and could not recall how the bruise was acquired, and the treatment nurse noted that a sling lift had been used earlier in the week and that CNAs were verbally educated on proper lift techniques and positioning. The DON later documented that the lift used did not go under the arms and that the resident had a history of easy bruising and skin tears, and acknowledged that CNAs sometimes assisted the resident by placing a hand under her arm for repositioning. During interviews, the LPN and DON confirmed awareness of the bruise and that it had been reported internally to the DON and Administrator, but the DON and Administrator both confirmed that the injury of unknown origin was not reported to the State Agency as required by facility policy and state law.