Failure to Investigate Resident's Injury
Penalty
Summary
The facility failed to implement its abuse policy regarding the investigation of an unknown injury for a resident. The policy, last reviewed on July 18, 2024, requires the use of an incident reporting system to report, investigate, and track all unusual incidents, including those of unknown origin. However, the facility did not complete an investigation into the cause of a resident's injury, which was necessary to rule out the potential for abuse and neglect. The resident, identified as Resident 28, complained of right leg pain, which was initially treated with Tylenol but proved ineffective. Subsequent medical evaluation revealed a tibial plateau fracture and ligamentous knee injury. Despite these findings, there was no documented evidence in the resident's clinical record indicating how the injury occurred. An interview with the Director of Nursing confirmed that the facility did not conduct an investigation into the injury, as required by their policy.
Plan Of Correction
1. Resident 28 has a completed Incident Report and investigation summary regarding the unknown Fracture. 2. DON/Designee will audit the past 30 Incident / Accident reports to determine if other injuries of unknown origin have been investigated properly. 3. DON/Designee will educate nursing Staff on making sure that incidents of unknown origin are resolved and abuse has been ruled out, and abuse prohibition policy. 4. DON/Designee will do a random audit weekly x4 and monthly x3 of Incident Reports to validate complete investigation including to rule out abuse for injuries of unknown origin. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.