Failure to Investigate and Monitor Injuries of Unknown Origin
Penalty
Summary
The facility failed to follow its policies and procedures to thoroughly investigate injuries of unknown origin for one resident. The resident had Parkinson’s disease, Parkinsonism, and dementia and was admitted on an unspecified date. On 10/16/25 at 2:00 AM, nursing staff documented a large purple discoloration on the resident’s right upper arm measuring 15 cm by 6 cm. The resident could not recall any incident that could have caused the bruising. The incident report and corresponding nursing progress note showed that no staff statements were obtained and no thorough investigation of the root cause of the injury was completed. Although the physician was notified and a message was left for the practitioner, there was no documentation on the Treatment Administration Record (TAR) that the bruise was monitored until it resolved, despite facility expectations that bruises be monitored daily for a week and then weekly until resolved. On 11/26/25 at 6:25 PM, another bruise of unknown origin was identified on the same resident. A CNA observed a 4 cm by 4 cm purple/blue bruise with yellow fading around the edges on the resident’s lower lumbar region while assisting the resident to the bathroom. The resident was unable to describe how the bruise occurred, and the incident report again lacked staff statements and evidence of a thorough investigation into the root cause. The nursing progress note documented the bruise and indicated that monitoring was set up and a note was placed to the provider, but there was no documentation of a comprehensive nursing or skin assessment. During interview, the DON acknowledged that these incidents were not reported to the State Agency and stated she did not think reporting was necessary based on the resident’s restlessness and flailing and inability to verbalize what happened. These actions were inconsistent with the facility’s Abuse, Neglect & Exploitation policy, which requires identification, reporting, and investigation of physical injuries of unknown source, including use of investigation worksheets, witness interviews, and collection of information for State Agency reporting.
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