Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. The resident sustained an injury to the left ankle while an unidentified CNA was assisting with putting on the resident's shoe. Medical records included a provider note documenting an evaluation and subsequent X-ray, which showed soft tissue swelling but no fracture. However, there was no nursing documentation regarding the occurrence of the injury or any monitoring of the resident's left foot following the incident. The facility's investigation consisted only of interviews with the resident, a family member, and a note from an OT student, who documented the resident's report of pain, bruising, and swelling. The OT student also recorded the resident's account that the injury occurred when an aide twisted the leg while putting on shoes. The investigation lacked evidence of interviews or observations involving staff who worked with the resident at the time of the incident. Additionally, there was no thorough documentation in the risk management portal as required by facility policy, and no evidence that witness statements were collected.