Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident with severe cognitive impairment. The resident was found with a reddish-blue bruise around the right eye, and was unable to provide a history of the injury. The facility's abuse prevention policy required a comprehensive investigation, including interviews and signed statements from all staff involved, as well as interviews with the resident or their roommate if the resident was unable to communicate. However, the administrator only spot-checked security footage without documenting the review, and did not obtain or document written statements from staff. The CNA Supervisor reported conducting only verbal interviews with two CNAs, but did not document these interviews, and both CNAs later stated they were not interviewed or asked for statements. Additionally, an LPN who was notified of the bruise was not interviewed about the incident. The administrator assumed the injury was caused by a fall, despite no documented falls for the resident, and did not interview staff from other shifts or obtain further evidence. There was no documented evidence to show that a thorough investigation, as required by facility policy, was completed regarding the resident's injury. The lack of documentation and incomplete staff interviews resulted in a failure to properly respond to and investigate the injury of unknown origin.