F0609

D

Failure to Investigate and Report Injury of Unknown Origin Near Resident’s Eye

Los Gatos, California Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The facility failed to investigate and report an injury of unknown origin after a family member observed a discoloration near a resident’s outer right eye and believed it to be a bruise. The resident had diagnoses including UTI, dysarthria, and muscle wasting/atrophy, and an MDS indicating severely impaired cognition with a BIMS score of 7. During interview, the resident could not recall how the discoloration occurred. The DON stated that when the family member reported a bruise on the resident’s head, she and the ADON assessed the area with the family member present and told the family it was not a bruise but a greenish discoloration from a vein. A treatment nurse also described the area as a skin discoloration that was being monitored.

Clinical documentation showed a physician order dated 12/5/25 for skin discoloration beside the outer right eye, with instructions to observe for swelling, skin breakdown, and bleeding every shift for 30 days, and a care plan problem for altered skin integrity related to this discoloration. The Weekly Non-pressure Ulcer Observation Tool documented that the family member stated it looked like a bruise and measured the discoloration as 0.5 cm by 0.1 cm. Progress notes later documented that the discoloration had resolved and that the MD was made aware, but there was no documentation explaining how the discoloration was acquired or that an investigation into a possible injury of unknown source was conducted. This was inconsistent with the facility’s Abuse Reporting Policy, which defines injury of unknown source and requires immediate initiation and documentation of a thorough investigation and reporting of any allegation of abuse or injury of unknown source to appropriate authorities within the required timeframe.