Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. The resident, who had severe cognitive impairment as indicated by a score of 1 out of 15 on the Brief Interview for Mental Status exam, was found to have a dislocated right shoulder after reporting pain upon waking. The incident report documented that only the certified nursing aides on the morning shift, when the injury was discovered, were interviewed. There was no documentation of interviews with staff from other shifts who had cared for the resident prior to the incident. Facility policy requires that, in cases of injuries of unknown source, the Director of Nursing or designee should interview all staff members who may have been involved, including those on previous shifts, and document their statements. However, the investigation did not include interviews with staff from the night or day prior to the discovery of the injury. The Director of Nursing acknowledged during an interview that she should have interviewed staff from the previous shift, but this was not done according to the incident report.