Failure to Report Injuries of Unknown Origin as Potential Abuse
Penalty
Summary
The facility failed to follow its abuse, neglect, and exploitation policy by not reporting injuries of unknown origin for one resident to the Abuse Coordinator and State Agency. The resident had Parkinson’s disease, Parkinsonism, and dementia and was unable to recall incidents that could have caused the bruising. On one occasion, an incident report dated 10/16/25 documented a large purple discoloration on the resident’s upper right arm measuring 15 cm by 6 cm, with the resident unable to recall any incident that may have caused the bruising. The nursing progress note for the same date confirmed the size and location of the bruise and noted that a message was left in the provider binder for practitioner review and that family would be notified by day shift, but there was no documentation that the Abuse Coordinator was notified. On another occasion, an incident report dated 11/26/25 documented a 4 cm by 4 cm purple/blue bruise with yellow fading around the edges on the resident’s lower lumbar region, discovered when a CNA was assisting the resident to the bathroom. The cause of the bruise was unknown, and the resident was unable to provide a description. The incident report showed that the physician, family member, and MDS nurse were notified, and a nursing progress note confirmed the findings and that the charge nurse was notified and monitoring was initiated, with a note placed to the provider. However, there was again no indication that the Abuse Coordinator was notified or that the incident was reported to the State Agency. In an interview, the DON acknowledged that these incidents were not reported to the State Agency and stated she did not think reporting was necessary due to the resident’s restlessness, flailing, and inability to verbalize what had happened, despite facility policy requiring reporting of physical injuries of unknown source as potential abuse.
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