OLATHE, CO - State inspectors found that Colorow Health Care LLC failed to properly investigate and document multiple instances of unexplained bruising on a resident's arms, violating federal regulations requiring facilities to protect residents from potential abuse and thoroughly investigate injuries of unknown origin.
Unexplained Bruising Discovered During Routine Documentation
During a complaint investigation on May 7, 2025, state surveyors uncovered significant lapses in how the facility handled and documented bruising found on Resident #3's arms over a period of several weeks. The investigation revealed that nursing staff had documented bruising and discoloration on the resident's forearms on February 4, 2025, during routine weekly nursing documentation, but this finding was never properly investigated or reported to facility administration.
The bruising documentation appeared again two weeks later. On February 18, 2025, following a resident-to-resident altercation that occurred the previous day, nursing staff documented what they described as "old bruising" on the resident's arms. However, the nursing note failed to provide critical details about these injuries, including their specific location on the arms, their appearance, or any assessment of when they might have occurred.
When state inspectors reviewed the resident's electronic medical record (EMR), they found no documentation explaining the origin of either the February 4 bruising or the "old bruising" noted on February 18. This gap in documentation represents a serious breach of standard nursing home protocols, which require detailed documentation of all injuries, regardless of their suspected cause.
Administrative Oversight Failures Revealed
The investigation exposed troubling gaps in administrative oversight at the facility. When interviewed by state inspectors, both the Nursing Home Administrator (NHA) and the Director of Nursing (DON) stated they were completely unaware of the bruising and discoloration documented in the February 4, 2025 weekly nursing documentation. This lack of awareness persisted for more than three months until the state inspection brought it to their attention.
The administrators' statements revealed several critical failures in the facility's communication and reporting systems. Despite clear documentation of unexplained bruising in the resident's medical record, this information never reached the facility's leadership team who would typically be responsible for initiating investigations into potential abuse or neglect.
The NHA acknowledged during the interview that according to the facility's own policies, bruises and injuries of unknown origin must be investigated to rule out abuse. She specifically stated that the documented February 4 bruises and the old bruises identified on February 18 should have been investigated but were not. The administrator admitted she should have been notified immediately about the bruising so she could have initiated an investigation to determine the cause.
The DON reported that prior to February 2025, the last documented bruising on Resident #3's arms occurred in December 2024, when the resident was reportedly combative during care. This two-month gap between known incidents makes the unexplained February bruising particularly concerning from a care oversight perspective.
Medical Significance of Proper Bruising Documentation
Unexplained bruising in nursing home residents requires immediate attention and thorough investigation for several critical medical reasons. Elderly residents often have fragile skin and may bruise more easily than younger individuals due to thinning skin, decreased collagen production, and medications that affect blood clotting. However, this increased vulnerability makes it even more important, not less, to document and investigate every instance of bruising.
When bruising appears without a known cause, healthcare providers must consider multiple potential sources. These can range from accidental injuries during transfers or daily activities to more concerning possibilities such as rough handling by staff, resident-to-resident altercations, or even self-injury in residents with cognitive impairment. Without proper investigation and documentation, patterns of injury that might indicate systemic problems or abuse cannot be identified.
The failure to document the specific location, size, color, and pattern of bruising eliminates crucial diagnostic information. Different types of bruising patterns can indicate different causes - for example, grip marks might suggest forceful handling, while bruising on the shins might indicate repeated contact with bed rails or wheelchair footrests. The color of bruising provides information about when an injury occurred, with fresh bruises appearing red or purple and older bruises progressing through stages of blue, green, yellow, and brown.
In this case, the February 18 note's reference to "old bruising" without any description of its appearance or comparison to the February 4 documentation represents a missed opportunity to establish a timeline of injuries. This information would have been essential for determining whether the resident was experiencing ongoing trauma or whether the February 18 observation was actually the same bruising noted two weeks earlier.
Industry Standards for Injury Investigation
Federal regulations and industry best practices establish clear protocols for handling unexplained injuries in nursing home residents. These standards exist to protect vulnerable residents who may be unable to report abuse or neglect due to cognitive impairment, fear of retaliation, or communication difficulties.
According to standard protocols, when nursing staff discover any unexplained injury, they must immediately document the finding with specific details including the exact location, size, color, and appearance of the injury. Photographs should be taken when possible to create a visual record. The discovery must be reported to the charge nurse and administrator without delay, typically within 2 hours of discovery or by the end of the shift at minimum.
A formal investigation should begin immediately, including interviews with all staff members who provided care to the resident during the timeframe when the injury could have occurred. The resident should be interviewed if cognitively able, and family members should be notified. Medical evaluation by a physician should occur within 24 hours to assess the injury and rule out medical causes such as bleeding disorders.
The facility must also create a risk management report and implement protective measures while the investigation is ongoing. This might include increased monitoring of the resident, review of care techniques with staff, or temporary reassignment of staff members if abuse is suspected.
Pattern of Documentation Failures
The investigation revealed a troubling pattern of incomplete and inadequate documentation that extended beyond the initial discovery of bruising. When physician examinations occurred on February 5 and February 17, 2025, neither encounter note documented whether bruising was present on the resident's arms, despite these visits occurring shortly after bruising had been documented by nursing staff.
The February 5 physician visit occurred just one day after the initial bruising documentation, when the resident was examined for lethargy and decreased intake. The physician's note stated that the resident's skin was examined and there were "no physical findings pertinent to the encounter," but failed to specifically address the bruising that had been documented the previous day.
Similarly, the February 17 physician visit, which occurred due to a family request to review pain control following the resident-to-resident incident, also failed to document the presence or absence of bruising on the resident's arms. This represents a significant oversight, as physician documentation of injuries is crucial for establishing medical evidence and ensuring appropriate treatment.
The facility's skin observation sheets for February 1-16, 2025, consistently marked "no" to the question about new skin issues, despite the February 4 documentation of bruising. This contradiction between different documentation systems suggests a breakdown in communication between staff members and a failure to maintain consistent, accurate records.
Additional Issues Identified
Beyond the primary violations related to unexplained bruising, the investigation uncovered several other concerning issues with the facility's documentation and investigation practices. The facility failed to provide skin observation sheets for dates after February 16, 2025, making it impossible for inspectors to verify whether proper skin assessments were being conducted.
When the NHA attempted to investigate the bruising after the state inspection, she discovered that the nurse who had documented the February 4 bruising no longer worked at the facility. The staff interview conducted on May 8 with the nurse who documented the February 18 injuries revealed that she could not recall any skin issues, suggesting inadequate documentation practices that relied too heavily on memory rather than detailed written records.
The facility's response to the state inspection findings included a promise to conduct retroactive staff interviews and documentation reviews. However, these after-the-fact investigations cannot adequately replace timely investigation that should have occurred when the bruising was first discovered. The delay of more than three months between the initial documentation and the investigation severely limited the facility's ability to determine what actually occurred.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Colorow Health Care LLC from 2025-05-07 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.