Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident who sustained a fractured humeral neck. The facility's policy requires that incidents of unknown origin be reported and investigated thoroughly, including reviewing events leading up to the incident and interviewing staff. However, the facility did not follow this policy in the case of the resident who was severely cognitively impaired and unable to explain the injury. The resident was involved in a fall from bed during care, where they landed on their knees on a fall mat. Initial assessments and X-rays did not reveal any fractures or acute findings, and the resident did not exhibit signs of pain immediately following the fall. It was only five days later that the resident showed signs of shoulder pain, and an X-ray revealed a humeral fracture, which was suspected to be a refracture of an old injury. Despite the discovery of the fracture, the facility did not document any attempts to investigate the source of the injury. The Director of Nursing confirmed that there was no evidence of an investigation into how the resident sustained the humeral neck fracture, and the facility attributed the injury to the fall without documented evidence. This lack of investigation into the injury of unknown origin constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Plan Of Correction
Step I - Unable to retroactively address for Resident 23. Step 2 - Review of last 30 days of falls to assure there was no occurrence of injury noted few days later attributed to fall. DON or designee. Step 3 - Education to nursing staff that occurrences of injury few days later require an investigation to assure injury was not related to something other than the fall. Staff educator or designee. Step 4 - Random audits on incidents with injury noted days later to assure the investigations occur. Weekly times 4, monthly times 2 - DON or designees. Step 5 - Results of audits to QAPI. Monthly times 2.