Failure to Investigate Resident Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, identified as Resident 42, who was reviewed for abuse. A clinical record review revealed that on December 30, 2024, a nurse noted a bruise on the right side of Resident 42's face, measuring 3 cm x 2 cm, with a dark bluish and purplish color. The bruise was located outside the right eye. The resident was known to be combative during care, and staff were instructed to walk away if the resident became combative to prevent self-inflicted injuries. However, there were no follow-up progress notes related to the event until January 22, 2025, after a surveyor inquired about the incident. The facility's investigation into the event was inadequate, as it did not include witness statements from staff regarding how the injury may have occurred, nor was there evidence of staff education on interventions for managing the resident's combative behavior. An interview with the Director of Nursing confirmed the lack of witness statements and staff education documentation. This deficiency was previously cited on May 22, 2024, indicating a repeated failure to comply with regulations prohibiting and preventing abuse, neglect, and exploitation of residents.
Plan Of Correction
Cited: Per follow up investigation, abuse and neglect was ruled out for resident 42. Like: Facility will do a two week look back of injuries of unknown origin to ensure a full investigation was completed. Education: DON/designee will educate nursing staff on the facility Abuse Policy and Procedure, Incident and Accident Investigations to ensure residents with injuries of unknown origins are fully investigated to rule out potential abuse/neglect. Audits: Residents with injuries of unknown origins will be audited weekly x4 then monthly x2 to ensure injuries are fully investigated. Results will be taken through QAPI.