Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, leading to a deficiency in compliance with regulatory requirements. The resident, who was cognitively intact and required assistance for daily care, suffered an ankle fracture. Despite the facility's policy mandating a thorough investigation for injuries of unknown origin, there was no documented evidence that such an investigation was conducted to rule out abuse or neglect as potential causes. The Director of Nursing interviewed the resident, who denied any abuse, and concluded the investigation without further action. However, there was no documentation to show that neglect was considered or ruled out as a cause for the fracture. This lack of a comprehensive investigation into the resident's injury of unknown origin resulted in a failure to meet the regulatory requirements for investigating and preventing potential abuse or neglect.
Plan Of Correction
I hereby acknowledged the CMS 2567-A, issued to Redstone Highlands Health Care Center for the survey ending March 20, 2025 and attest that all deficiencies listed on the form will be corrected in a timely manner. This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Redstone Highlands Healthcare Center agrees with the allegations and citations listed on the statement of deficiencies. Redstone Highlands Healthcare Center maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Redstone Highlands Healthcare Center's written credible allegation of compliance. By submitting this plan of correction, Redstone Highlands Healthcare Center does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Redstone Highlands Healthcare Center reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. Resident 24 was assessed and noted to have no adverse effects related to the investigation of ruled-out neglect from the incident dated October 12, 2024. The resident is followed to ensure psycho-social needs are met. No new orders from the physician. The resident has had no adverse effects from the completed investigation of injury of unknown origin. A facility-wide sweep of all residents with pain scales presenting with unidentified pain source, if applicable. Any issues identified were corrected at the time of discovery, and an investigation will be initiated to rule out abuse/neglect and identify the cause, if applicable. The whole house staff was educated on the Abuse / Neglect Prohibition policy and procedure. The Director of nursing (DON) or designee will conduct audits to ensure all pain scales with unidentified sources are investigated to rule out abuse/ neglect to completion and documented weekly for 4 weeks, then monthly for 2 months. Identified issues will be addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.