Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and a history of falls and physical aggression. The resident, who required extensive to total assistance with activities of daily living and had diagnoses including dementia and depression, was found to have swelling and discoloration in his right hand. Progress notes indicated that the resident was unable to communicate the cause of the injury, and staff were unaware of how the injury occurred. Despite documentation of the injury and subsequent diagnosis of a closed, displaced fracture of the right middle finger, there was no evidence of an internal investigation or incident report regarding the injury. Interviews with nursing staff and the DON revealed that the injury was not witnessed, and there was no documentation or report made to the State Agency (SA) as required by facility policy. The DON and consulting administrator both acknowledged that the injury should have been investigated and reported, but confirmed that no such actions were taken. The facility's risk management records and electronic medical record did not contain any documentation of an investigation or incident report related to the injury. The facility's policy on conducting internal investigations outlines steps such as reviewing documents, interviewing staff and residents, and collaborating with administration or outside authorities. However, these procedures were not followed in this case, as there was no evidence of an investigation or reporting of the resident's injury of unknown origin, despite the resident's vulnerability and inability to communicate the cause of the injury.