Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate injuries of unknown origin for a resident who had significant bruising on two occasions. The facility’s abuse prohibition policy defines injuries of unknown origin and requires that an initial investigation be started, witness statements obtained, appropriate administrative personnel notified, and a comprehensive internal investigation carried out, with documentation in the clinical record. The resident, readmitted in July 2025, had diagnoses including chronic inflammatory demyelinating polyneuropathy and lymphedema. Progress notes showed that on 8/26/2025 a large bruise was noted on the right upper buttock, and on 9/8/2025 staff found a large, deep purple bruise on the left proximal thigh measuring approximately 18 cm by 22 cm during care at 12 AM. Further record review did not show any evidence that an investigation was conducted to determine the origin of either bruise. In an interview, the Director of Nursing Services stated that new bruising should trigger an investigation to determine etiology and be documented in the clinical record, but he was unable to provide evidence that such investigations were completed for the bruising documented on 8/26/2025 and 9/8/2025.
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