Failure to Conduct Thorough Investigations of Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that injuries of unknown origin were thoroughly investigated for two out of five residents reviewed for potential abuse. One resident with severe Alzheimer's dementia and significant physical care needs was found with multiple bruises on her legs and wrist. Although staff noted that the bruises appeared to align with equipment and furniture, the investigation documentation lacked detailed staff interviews and did not provide evidence supporting the conclusions about the source of the bruising. Statements from staff were minimal, and there was no documentation indicating that staff were asked about possible events leading to the injuries. Another resident with dementia and total care needs was found to have a new bruise on the right eyelid. The investigation report attributed the bruise to a transfer with a hoyer lift, but staff statements were limited, with most reporting they did not notice the bruise and no further details provided. The Assistant Director of Nursing, who completed the final investigation note, confirmed that there was no additional documentation to support the determination of the cause of the injury. The investigation did not include evidence or documentation of interviews with other residents or a thorough assessment of possible causes. Facility policy requires that injuries of unknown source be classified and investigated when the source is not observed or explained, and that written statements be obtained from all relevant staff. The policy also requires attempts to contact staff from previous shifts and tracking of such incidents by Quality Assurance. However, the investigations reviewed did not meet these requirements, as documentation was incomplete and lacked evidence of a comprehensive investigation process.