Failure to Report Injury of Unknown Origin Involving Eye Bruising
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an injury of unknown origin involving suspected abuse or neglect to the state agency (HHSC) for one resident. The resident was an elderly male with Alzheimer’s disease, obstructive sleep apnea, depression, vertigo, impaired vision in the right eye due to macular degeneration and glaucoma, and a history of falls. His MDS showed a BIMS score of 2, indicating severe cognitive impairment, and he required partial to moderate assistance with bed mobility, transfers, and supervision/touching for walking, using a walker or wheelchair. His care plan identified him as cognitively impaired, at risk for elopement and falls, with prior falls including one that had resulted in a right eye bruise, and directed staff to monitor, document, and report pain, bruises, and changes in condition. On or about early February, staff observed discoloration and bruising to the resident’s right eye area without a witnessed event or clear explanation from the resident. Nursing progress notes documented that a nurse was called to the dining area and shown a light bruise to the right eye; the resident denied pain but could feel the area when touched, vital signs were stable, and no change in level of consciousness or other injuries were noted. Subsequent notes described the area as a 3.0 cm x 3.5 cm light bruise near the right eye, with the resident unable to describe what happened. A photograph taken by a nurse showed purple bruising on the upper eyelid and above the eyebrow, with red bruising on the eyelid crease and under the eye. Over the next days, documentation reflected that the discoloration progressed to a “black eye” with multiple colors (purple, green, blue, yellow) around the corner and under the right eye, while the resident continued to deny pain and could not explain the cause. Multiple staff statements and interviews confirmed that the injury was unwitnessed and that the resident, due to impaired cognition, could not reliably report how it occurred. CNAs and nurses reported noticing a bruise or discoloration to the right eye during rounds or shift changes, but there was no consistent account of when the injury first appeared or how it happened. The DON stated that, based on her assessment, she believed the resident had fallen and hit the corner of his nightstand while wearing his CPAP mask, but this was not observed by staff and the resident’s explanation was limited to saying he “rolled over and felt it burn.” The Administrator acknowledged being notified of the injury by nursing staff and stated she did not report the incident to HHSC because she believed it did not meet the criteria for an injury of unknown origin requiring reporting. The facility’s own abuse policy defined an injury of unknown origin as one not observed, not explained by the resident, and suspicious due to extent or location, and required immediate reporting of any allegation of abuse to the Administrator and appropriate authorities. Despite the unwitnessed nature of the injury, the resident’s inability to explain it, and the suspicious location and progression of the bruising, the facility did not report the incident to HHSC, leading to the cited deficiency for failure to timely report suspected abuse, neglect, or theft and the results of the investigation to proper authorities.
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