Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report and investigate an injury of unknown origin for a resident who was noted to have pain, bruising, and swelling to her right hand and wrist, as well as discoloration to her left wrist. The resident had a complex medical history, including dementia, schizophrenia, bone disorders, and muscle weakness, and required assistance with personal care. Documentation in the resident's care plan and progress notes indicated new skin discoloration, complaints of severe pain, and swelling, but there was no evidence that these findings were reported as required. Multiple staff members, including the DON, RNs, and the treatment nurse, reviewed the clinical record and confirmed that no investigation was conducted into the source of the injuries, nor was the incident reported to the appropriate authorities as an injury of unknown source. The DON stated she was unaware of the resident's issues and could not provide documentation of an investigation or report. The treatment nurse also indicated she was unaware that such injuries needed to be reported and investigated. The facility's policy required prompt reporting and thorough investigation of all injuries of unknown source, but this was not followed in the case of this resident. The lack of investigation and reporting resulted in the resident's injuries not being addressed according to regulatory requirements, and delayed medical intervention for the resident's condition.