Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly and promptly investigate an injury of unknown origin for a resident with severe cognitive impairment and multiple psychiatric and neurological diagnoses. The resident, who required substantial assistance for toileting and was at risk for skin tears and bruising, was observed with multiple bruises and a bandage above her right eye. She reported a fall as the cause of her facial bruise but could not recall how she injured her hand. Nursing notes documented an incident where the resident was resisting care, was in pain, and had discoloration on her right hand, but declined pain medication and ice. The investigation into the incident was incomplete. The DON stated she checked on the resident and saw that an x-ray was ordered, but only interviewed the nurse involved and not the CNAs who were present during the incident. The DON could not recall the names of the CNAs involved and did not obtain their statements, despite being asked to do so by the NHA. Staff interviews revealed that the resident was swatting at staff during care, complained of pain, and was observed crying, but there was inconsistency in staff recollection and documentation of the event. One CNA stated she was never asked to provide a statement about the incident. Facility policy required immediate and thorough investigation of alleged abuse, neglect, or injuries of unknown origin, including identifying and interviewing all involved persons and documenting the investigation. However, the facility did not follow these procedures, as not all involved staff were interviewed or provided statements, and the investigation remained incomplete at the time of the survey.