Failure to Interview Other Residents During Investigation of Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident with severe cognitive impairment and multiple medical conditions, including dementia and palliative care needs. The resident was found to have discoloration and bruising on both wrists, which staff and hospice personnel noted had appeared and disappeared over several weeks. On a subsequent assessment, a large hematoma was observed on the resident's left forearm. The resident was unable to provide reliable information due to severely impaired cognition, and the activated Power of Attorney for Healthcare was involved in discussions about the resident's care and behaviors. Although the facility initiated an internal investigation by interviewing the resident, all staff who had contact with the resident during the relevant period, and the resident's POAHC, the investigation did not include interviews with other residents as required by the facility's Abuse Prevention policy. The policy specifically directs that investigations of potential abuse or injuries of unknown origin should include interviews with other residents who received care from the same staff. The Director of Nursing confirmed that this step was omitted during the investigation.