Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to promptly and thoroughly investigate an injury of unknown origin for one resident. According to the facility's Abuse Prevention Program, nursing staff are responsible for reporting incidents such as bruises or injuries of unknown origin, and the Nursing Supervisor must assess the resident, review documentation, and report to the administrator. The policy also requires a final investigation report to be completed within five working days, including detailed information about the incident, witnesses, and a summary of interviews, with a written report sent to the Department of Public Health. A resident with multiple diagnoses, including encephalopathy, mild dementia, and use of anticoagulants, was found to have a bruise on the right buttock that was unwitnessed and of unknown origin. The injury was documented in the resident's record, noting that the resident was unable to provide details and there were no witnesses. During an interview, the administrator acknowledged that a complete investigation was not conducted because they were unaware of the incident until it was brought up by the surveyor.