Failure to Investigate Injury of Unknown Origin and Alleged Aggressive Care
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an allegation of injury of unknown origin for one resident. Staff discovered bruising resembling finger marks on the resident's upper arm, and the resident's family had filed a grievance about aggressive care the day before the bruising was found. Despite this, there was no documented grievance or investigation regarding the bruising, and the event was not recorded in the resident's event history. The resident, who was moderately cognitively impaired and dependent on staff for most activities of daily living, reported pain and showed the bruising to staff and family, but the cause was not determined or documented. Interviews revealed that the nurse practitioner was not notified of the bruising, and the direct care staff were not informed or questioned about the incident. The resident described feeling unsafe with a particular nursing assistant, reporting verbal aggression and rough care, but there was no evidence that these concerns were thoroughly investigated. The care plan did not reflect the resident's risk for abuse or require two staff for all care, despite staff awareness that this was needed. The facility's investigation into aggressive treatment did not include interviews with cognitively impaired residents or direct observation of care practices. Documentation and follow-up were lacking, as the facility did not log the incident as required by policy, nor did they conduct or document interviews with all relevant staff or witnesses. The facility's policy mandates prompt and thorough investigation of all suspected abuse or injuries of unknown source, including physical examination, interviews, and documentation, but these steps were not completed. The results of the investigation were not reported to the appropriate parties, and the incident was not analyzed for prevention of future occurrences.