Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. Facility policy on Occurrence Prevention, Documentation, and Reporting, last reviewed July 21, 2026, required that all sections of the incident report be completed to the best of staff’s ability, including details surrounding the incident and statements from staff or individuals involved in the resident’s care or the situation prior to or during the incident, as well as those involved in the incident response. The resident’s quarterly MDS dated September 16, 2025, showed a BIMS score of 9, indicating moderate cognitive impairment. On October 6, 2025, progress notes documented a bruise to the right front axilla measuring 3.56 cm by 4.34 cm, and an additional note the same day documented that an LPN observed a dark bruise to the resident’s right upper arm, with the resident unsure how the bruise occurred. Review of facility documentation showed that only one staff statement was obtained, from Employee E4, indicating that a nursing assistant from the outgoing shift had reported the bruise to Employee E4. No other statements were obtained from staff who had provided care prior to identification of the bruise. The documentation also noted that the resident was independent with self-propelling a wheelchair, able to move upper and lower extremities independently, and had thin, fragile skin that increased the risk for skin injury. In an interview on January 23, 2025, licensed staff (Employee E3) and the Director of Nursing confirmed that no additional staff statements were collected and that no further investigation was conducted because the bruise’s location was considered consistent with contact from a bed enabler.
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