Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a comprehensive investigation into an injury of unknown origin for a resident with severe cognitive impairment and a diagnosis of dementia. The facility's policy requires that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source be thoroughly investigated by the administrator or designee. However, in this case, the investigation was not completed as required. The resident's quarterly Minimum Data Set (MDS) indicated severe cognitive impairment. A nursing progress note revealed that the resident had a hematoma and bruise on the forehead, with an assessment suggesting the injury was likely caused by hitting the head against a wall or headboard. The Director of Nursing confirmed that the protocol to interview staff from the relevant shifts to determine the cause of the injury was not followed, resulting in an incomplete investigation.
Plan Of Correction
Facility cannot retroactively investigate resident 47's bruise of unknown origin. 2. DON performed a facility audit to ensure current residents have no bruises of unknown origin. None were found. Current and new admit residents are at risk for bruises of unknown origin. 3. DON, or designee, will educate facility staff on Policy of bruises of unknown origin when they observe a bruise on a resident. DON, or designee, will educate staff on providing a written statement regarding observed bruises. 4. DON, or designee, will perform random audits of nursing notes and incident reports for bruising of unknown origin weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.