Inadequate Investigation of Resident's Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident, identified as Resident 5, to rule out abuse or neglect. The facility's policy requires the Director of Nursing or designee to conduct investigations, review accident/incident reports, obtain written statements from staff, and interview witnesses. However, there was no documented evidence that the investigation was expanded to include interviews with all staff who had potential contact with the resident around the time she complained of pain and swelling in her right wrist. The Director of Nursing confirmed the lack of documentation for a comprehensive investigation. Resident 5, who has severe cognitive impairment due to Alzheimer's and Parkinson's diseases, was readmitted to the facility after a hospital stay. Upon readmission, she had scattered bruising on her hands and arms. A subsequent skin assessment noted multiple small bruises on her hands. A nursing note indicated increased pain and swelling in her right wrist, which was not thoroughly investigated. Witness statements from staff revealed that some aides did not have contact with the resident, but there was no evidence of further interviews with other staff members who might have interacted with her.
Plan Of Correction
1. Physical assessment completed by a Registered Nurse on Resident 5. Incident report and investigation of Resident 5's injury of unknown cause on November 19, 2024 that included wrist swelling and pain to her right hand/wrist with movement was completed to rule out abuse. Immediate re-education provided to Licensed Nursing Staff, including licensed agency staff, on facility policy regarding reporting incidents and accidents and completing incident reports/investigations thoroughly with staff interviews to rule out abuse. 2. All residents with injuries of unknown cause have the ability to be affected by this alleged deficient practice. A whole house audit of current incident and accident reports has been completed to ensure each incident report with an injury of unknown cause has a thorough investigation, including staff interviews, to rule out abuse. 3. Facility Staff, including Agency Staff, were re-educated on facility policies regarding abuse prevention and reporting and abuse, neglect and mistreatment of residents including importance of reporting, investigating and obtaining/providing witness statements. The Charge Nurse will be notified of incidents and/or accidents including injuries of unknown origin, so medical attention may be provided and a physical assessment and thorough investigation, including staff interviews, can be completed to rule out abuse. Incident reports are reviewed daily for completion, including review of staff interview statements. 4. Director of Nursing/designee will audit injuries of unknown origin to ensure that their completed incident reports include a thorough investigation with staff interview statements to rule out abuse weekly times six weeks, monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.