Failure to Investigate Injury of Unknown Origin to Resident’s Shoulder/Armpit
Penalty
Summary
The deficiency involves the facility’s failure to investigate an injury of unknown origin in accordance with its own incident/accident and abuse policies. The facility’s policies required staff to report, investigate, and document incidents and accidents, including injuries of unknown origin, and to conduct an immediate investigation when there was suspicion or reports of abuse, neglect, or exploitation. These policies also required identification and interviewing of all involved persons and complete documentation of the investigation. Despite these written requirements, the facility did not complete a full investigation when a large bruise of unknown origin was identified on a resident’s right shoulder/armpit area. The resident involved 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. A quarterly MDS showed moderate cognitive impairment (BIMS score of 8), dependence on staff for all ADLs, substantial/maximal assistance needed for rolling in bed, and total dependence for transfers. The resident was also receiving Eliquis 2.5 mg twice daily. During surveyor observation, the resident was seen sitting up in bed with a large bruise on the right shoulder/armpit and was unable to state how the bruise occurred. Record review showed that on a prior date, a hospice CNA had notified the treatment nurse 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 did not recall how the bruise was acquired. Staff notes referenced use of a sling lift earlier in the week and staff education on proper lift and positioning techniques, and the DON documented that the lift used did not go under the arms and that the resident was an easy bruiser. However, the DON later acknowledged being unsure whether an incident report and investigation were completed, and both the DON and the Administrator confirmed that a full investigation into this injury of unknown origin was not conducted, despite the facility’s policies requiring such an investigation.
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