Failure to Adhere to Abuse Investigation Policy After Injury of Unknown Origin
Penalty
Summary
The facility failed to adhere to its abuse policy following an incident involving an injury of unknown origin for one resident. The resident, who had multiple diagnoses including type 2 diabetes, PTSD, and depression, was found to have a red, swollen, and painful pinky finger, which was later confirmed by x-ray to be a nondisplaced fracture. The resident was cognitively intact and did not recall any fall or incident that could have caused the injury. The facility reported the incident to the appropriate authorities and documented the event, but the internal investigation was unsubstantiated due to the resident's underlying bone conditions. Despite the reporting, the facility's investigation did not include interviews with staff, family, visitors, other departments, or other residents, as required by the facility's abuse policy. Interviews with facility staff, including the RN, CNA, DON, ADON, and Administrator, revealed that the expected process for investigating injuries of unknown origin included interviewing all relevant parties and obtaining written, signed statements. However, in this case, these steps were not followed, and the investigation documentation lacked evidence of comprehensive interviews. The facility's policy clearly stated that all allegations of abuse, including injuries of unknown origin, must be thoroughly investigated with interviews of all potential witnesses and involved parties, and that these interviews should be documented in writing. The failure to conduct and document these interviews represented a deviation from the established policy and resulted in an incomplete investigation of the incident.