Failure to Investigate Alleged Violation and Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged violation involving a skin tear on a resident's left arm, which was not timely assessed to rule out abuse or neglect. The incident was first identified by an LPN who noticed an open area on the resident's arm, which appeared to be a bruise that had opened. The LPN cleansed and wrapped the wound but did not report it in the 24-hour report or notify a registered nurse for further assessment. The incident report was not signed by the physician until several days later, and there was no documented evidence of a timely investigation. The resident involved had a history of dementia with behavioral disturbances, diabetes, and a history of falls. The care plan indicated the resident required extensive assistance with activities of daily living and was at risk for impaired skin integrity due to fragile skin. Despite these known risks, the facility did not conduct a timely investigation or notify the medical provider about the injury. Staff interviews revealed that the resident was combative during care, which may have contributed to the skin tear, but no thorough investigation was conducted to rule out abuse or neglect. The Director of Nursing and other staff members failed to follow the facility's policy for reporting and investigating alleged violations. The Director of Nursing did not report the injury of unknown origin to the appropriate authorities and did not obtain staff statements or conduct interviews. The resident's statement that they were not harmed by staff was taken as sufficient evidence to rule out abuse, despite the lack of a comprehensive investigation. The Medical Director was also unaware of the injury, indicating a breakdown in communication and reporting within the facility.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 F610-Investigate/Prevent/Correct Alleged Violation: Crouse Community Center will ensure that allegations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated. This includes measures to prevent further abuse, neglect, exploitation, or mistreatment while investigation is in progress and the incident is reported to the Administrator/Director of Nursing within 2 hours to ensure appropriate corrective actions are taken if alleged violation is verified. Corrective Action: Incident report and investigation was completed for Resident # 25. Upon investigation of the incident, root cause analysis and witness statements have determined it to be non-reportable. The bruising/skin tear was considered accidental secondary to Dementia with behaviors and fragile skin. Plan of correction includes continued application of arm protectors, use of 2 CNAs with all cares. Medication management will be reviewed to increase dose of Anti-Anxiety and Pain medication due to her behaviors. Other Residents: All licensed staff will be re-educated with our policy and procedures for reporting injuries of unknown etiology. All residents with an injury of unknown origin will have a skin assessment completed by a registered nurse with provider notification directly following assessment to obtain a treatment order if indicated. The RN will then initiate an Incident report with investigation if needed. Systemic Changes: Incident reporting of injuries of unknown origin will be included in facility orientation and annual Inservice training with Residents Rights and Abuse Reporting. Incident reports of injuries of unknown etiology must be reported immediately to the RN Nurse manager or RN Supervisor on duty to initiate the investigation, notify provider, and implement a treatment if indicated. After thorough investigation is complete, if abuse or serious bodily injury is suspected, the Director of Nursing will be notified and report the incident to the appropriate agency within 2 hours. Monitoring: Audits will be conducted by the Director of Nursing monthly on investigations of injuries of unknown origin. The audit will be reported to QAPI monthly with 100% compliant threshold expected. Responsible Party: Director of Nursing