Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who was found to have acute, minimally displaced right lateral fractures of the 10th and 11th ribs. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and metabolic encephalopathy, was noted to have fallen on one occasion, but did not exhibit pain, bruising, or complaints immediately following the fall. Staff interviews confirmed that the resident had no pain or abnormal findings in the days following the fall, and no further incidents or injuries were reported until the resident began complaining of pain several days later. On the day the pain was first reported, staff observed the resident guarding his right side and expressing discomfort during movement. A body check was performed, and an X-ray was ordered, which revealed the rib fractures. Multiple staff members, including LPNs and CNAs, stated that the resident had not experienced any new falls, injuries, or incidents between the initial fall and the onset of pain. The physician also noted the unusual delay in the onset of pain and questioned the attribution of the fractures to the earlier fall, given the absence of symptoms immediately after the incident. Despite the discovery of the fractures and the lack of a clear cause, the facility did not conduct a thorough investigation into the injury of unknown origin. The Director of Nursing acknowledged that there was no formal investigation, only informal notes about staff conversations. The facility was unable to provide an investigation report as required by its own Abuse and Prevention Program, which mandates a formal process for injuries of unknown source, including interviews, documentation review, and a final report.