The unexplained injury occurred around the same time another resident hit his roommate with a wooden stick during a dispute over stolen money, according to federal inspection records from August. Neither incident was properly reported to the Department of Public Health, police, or the state ombudsman.
Resident 5, who had severe cognitive impairments and couldn't communicate what happened, was discovered with discoloration under his left eye and ear on August 6. When inspectors observed him six days later, the bruise stretched from the outer eye to the inner eye, measuring approximately 3.8 centimeters by 2.5 centimeters. The center was raised and dark purple, with the rest showing reddish-yellow coloring and a purple line underneath.
The Assistant Director of Nursing told inspectors that Resident 5 "may have scratched himself or hit his head against the siderail but that no one had witnessed the events that lead up to the bruising." She admitted the bruise wasn't consistent with a scratch.
No investigation was completed. The incident wasn't reported to outside agencies.
The Assistant Administrator acknowledged to inspectors that Resident 5's bruise "would be considered an injury of unknown origin because Resident 5 was confused and unable to verbalize what had happened and no one witnessed what lead up to the injury." She confirmed that such injuries must be investigated and reported to the ombudsman, police, and Department of Public Health.
The facility also failed to conduct required 72-hour monitoring visits to ensure the resident's safety after the injury.
Two days before Resident 5's injury was discovered, his roommates were involved in a violent altercation that also went unreported to state authorities.
Resident 4 accused his roommate, Resident 3, of stealing $214 from his debit card after they ordered food together. According to facility records, Resident 3 had photographed Resident 4's debit card, including the security code, and asked for the address associated with the card. When Resident 4 checked his balance, it had dropped from $814 to $600.
During the confrontation on August 4, Resident 3 "became upset used racial slurs and threw ice from the cup" at Resident 4, according to interdisciplinary team meeting notes. Resident 4 responded by hitting Resident 3 on the arm with a wooden stick, causing a skin tear and discoloration.
Resident 4 told staff that "while he doesn't care about the money he is upset by the racial slurs."
The facility called 911 during the incident, but the Social Worker Assistant confirmed to inspectors that there was "no documented evidence that physical abuse was reported to the Ombudsman nor to the Department of Public Health." No 72-hour monitoring was conducted for either resident involved in the altercation.
Both residents had the mental capacity to consent to treatment, according to their medical records. Resident 3 was cognitively intact and required partial to moderate assistance with daily activities. Resident 4 was also cognitively intact despite having hemiplegia and difficulty swallowing following a stroke.
The Social Worker Assistant told inspectors that reporting to the Department of Public Health "was to ensure that facility had done what they needed to do and for the safety of the patient."
Temple Park Convalescent Hospital's own policies require reporting allegations of abuse, neglect, and resident-to-resident incidents that affect health and safety. The facility's abuse prevention program policy states that administration must "protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual."
The policy also requires staff to "identify and assess all possible incidents of abuse" and "investigate and report any allegations of abuse within timeframes as required by federal requirements."
Federal inspectors found the facility violated regulations requiring nursing homes to protect residents from abuse and ensure incidents are properly investigated and reported. The violations affected multiple residents and posed minimal harm or potential for actual harm.
The 204-bed facility on West Temple Street serves medically fragile residents requiring skilled nursing care. The administrator is responsible for directing all facility activities "to assure that the highest quality of care is provided," according to the job description reviewed by inspectors.
When Resident 3 was asked about his skin tear the day after the wooden stick incident, he denied pain or discomfort. But the failure to investigate Resident 5's unexplained black eye left unanswered questions about how a vulnerable dementia patient sustained significant facial injuries while under the facility's care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Temple Park Convalescent Hospital from 2024-08-09 including all violations, facility responses, and corrective action plans.
Additional Resources
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