Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an incident involving an injury of unknown origin for one of three sampled residents. The resident, who had a history of multiple medical conditions including type 2 diabetes, depression, and osteopenia, reported pain in the left pinky finger, which was found to be red, swollen, and fractured upon x-ray. 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 resident's statement, but the investigation was deemed unsubstantiated based on the x-ray findings and the resident's lack of recollection. Despite the facility's policy requiring a thorough investigation—including interviews with the person reporting the incident, witnesses, the resident or representative, staff members in contact with the resident, the resident's roommate, family members, and visitors—there was no evidence that such comprehensive interviews were conducted. The investigation documentation lacked statements from staff, family, visitors, other departments, or other residents who may have had relevant information about the incident. Interviews with facility staff, including the DON, ADON, and Administrator, confirmed that the expected process would involve obtaining written, signed, and dated statements from all potentially involved parties, but this was not done in this case. The deficiency was further highlighted by staff interviews, which revealed an understanding of the required investigative process, yet the actual investigation for this incident did not follow those protocols. The Administrator acknowledged that interviews were not conducted because the resident denied issues with staff, but also stated that interviews are required during such investigations. The facility's failure to follow its own policy and thoroughly investigate the injury of unknown origin resulted in an incomplete investigation for the resident.