THORNTON, CO - A federal inspection revealed that Skylake Post Acute failed to properly investigate an alleged physical abuse case involving a 76-year-old dementia patient who was discovered with suspicious bite marks on his forearm.
Discovery of Unexplained Injury
The incident came to light on April 9, 2024, when a hospice aide discovered what appeared to be bite marks on the resident's left forearm. The 76-year-old patient, who had been diagnosed with Alzheimer's disease and severe cognitive impairment, was unable to explain how the injury occurred.
The resident's family representative, who visited daily, received a call from the hospice nurse asking about the bite marks. This was the first notification the family had received about any injury. The representative had seen the resident the previous day at lunch and confirmed no bite marks were present at that time, establishing a narrow timeframe for when the injury occurred.
When the family representative arrived at the facility, she observed multiple teeth marks that had broken the skin on the top of the resident's forearm near the wrist. The marks formed a crescent pattern with several individual tooth impressions, and the wounds had begun to scab over with surrounding bruising extending approximately two inches from the bite site.
Physical Evidence Suggests External Source
The placement and pattern of the bite marks raised immediate concerns about their origin. The family representative noted the bite was positioned vertically along the top of the forearm - a location and orientation that would be extremely difficult for someone to inflict upon themselves.
The hospice registered nurse who later assessed the wound on April 11th documented that the injury showed "a pattern of a full set of upper teeth and partial bottom teeth" in a placement that was "unlikely that he would have done it himself." This professional assessment contradicted staff suggestions that the resident had self-inflicted the injury.
Medical research indicates that self-inflicted bite wounds typically occur on more accessible areas such as hands, fingers, or the inside of arms where a person can comfortably position their mouth. The vertical positioning on the upper forearm would require an awkward and unnatural body position that would be particularly challenging for someone with dementia and mobility limitations.
Facility Response Falls Short of Standards
When confronted about the injury, facility staff provided inconsistent responses and failed to conduct the thorough investigation required by their own policies. The facility's "Abuse, Neglect, Exploitation or Misappropriation" policy explicitly states that all reports of potential abuse "are reported to the local, state and federal agencies and thoroughly investigated by facility management."
Licensed Practical Nurse #2, who was the resident's primary nurse and had been administering medications and documenting behavior monitoring throughout April, initially told the family representative she believed the resident had bitten himself. However, when interviewed by inspectors, LPN #2 claimed she "was not his nurse" and "did not assess him at that time or see the bite wound," despite medical records showing she had been his assigned nurse.
Licensed Practical Nurse #3, the memory care unit manager, denied any knowledge of the bite marks when interviewed by federal inspectors. This directly contradicted both the family representative's account of speaking with her about the incident and hospice documentation showing LPN #3 had called the hospice nurse expressing anger that the family knew about the injury before facility staff had assessed it.
Documentation Gaps Reveal System Failures
A critical finding was the complete absence of documentation about the bite marks in the facility's electronic medical records. No incident report was filed, no assessment was conducted, and no investigation was initiated despite clear facility policies requiring such actions for injuries of unknown origin.
The facility's "Investigation Injuries" policy defines an injury of unknown source as one where "the source of the injury was not observed by any person or the source of the injury could not be explained by the resident" and is "suspicious because of the extent of the injury, the location of the injury, the number of injuries at one particular point in time."
The bite marks clearly met these criteria, yet staff failed to complete the required facility-approved accident/incident form or disseminate information to appropriate administrators as mandated by policy.
Ongoing Safety Concerns
The hospice nurse documented observing "several bruises, scratches and other injuries of unknown origin" on the resident over the subsequent weeks, with no explanations provided for how these injuries occurred. This pattern suggested ongoing safety issues that were not being addressed.
The resident was known to wander into other residents' rooms, which "startled some residents and was bothersome" according to facility staff. The hospice nurse noted "a lot of residents on the unit who were physically aggressive toward other residents," creating a potentially dangerous environment for vulnerable patients like this resident who had dementia and was unable to protect himself or report incidents.
Medical protocols emphasize that residents with cognitive impairments require enhanced monitoring and protection precisely because they cannot advocate for themselves or provide reliable accounts of incidents. The failure to investigate potential abuse leaves these vulnerable individuals at continued risk.
Regulatory Requirements and Industry Standards
Federal regulations require nursing homes to ensure residents are free from abuse and to immediately investigate any allegations of mistreatment. The facility's own policies aligned with these requirements but were not followed in practice.
Industry best practices call for immediate medical assessment of suspicious injuries, comprehensive documentation, notification of administrators and regulatory agencies, and implementation of protective measures to prevent recurrence. None of these steps were adequately completed in this case.
The inspection classified this as a violation with "minimal harm or potential for actual harm," but the failure to investigate and protect a vulnerable resident could have led to more serious consequences if the pattern of unexplained injuries had continued unchecked.
This case highlights the critical importance of robust incident reporting systems and staff training to recognize and respond appropriately to potential abuse situations, particularly involving residents with dementia who may be unable to report incidents themselves.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skylake Post Acute from 2024-06-14 including all violations, facility responses, and corrective action plans.
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