Failure to Investigate Unexplained Resident Injuries
Penalty
Summary
The facility failed to conduct a thorough investigation after a nurse discovered a resident with multiple unexplained injuries, including a bruise on the chest, an abrasion above the right eye, a skin tear on the nose, and an abrasion on the right elbow. The resident, who was cognitively intact but had some confusion at the time, could not recall how the injuries occurred. The facility's policies required a complete investigation, including staff statements, body assessment, and timely notifications, when injuries of unknown source were identified. However, documentation and interviews revealed that the source of the injuries was not clearly established, and the required investigative steps were not fully completed. The resident had significant medical history, including congestive heart failure, peripheral vascular disease, end stage renal disease, diabetes, and an above-knee amputation. The resident required substantial assistance with mobility and transfers and had a history of falls. Progress notes indicated that the resident reported rolling out of bed, but staff were unsure who assisted the resident back to bed, and there was a lack of documentation regarding the incident. The Director of Nursing (DON) and Administrator acknowledged that the investigation was incomplete, and staff statements were not obtained as required by policy. On the night of the incident, the facility was staffed primarily by agency nurses and facility CNAs. Interviews with agency staff indicated inconsistent familiarity with facility policies and procedures, and the DON confirmed that agency staff were not in-serviced regarding the incident. The facility did not complete a full investigation into the injuries, did not ensure all staff were interviewed, and did not provide in-service training to agency staff involved, as required by their own policies for injuries of unknown origin.