Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with significant medical conditions, including hemiplegia, chronic kidney disease, epilepsy, atrial fibrillation, mild cognitive impairment, and chronic pulmonary embolism. The resident, who was dependent on staff for most activities of daily living and had impaired cognition, was found with a large, painful hematoma on the right forearm during a medication pass. The resident was sent to the emergency department for evaluation, where the injury was attributed to a fall, but conflicting accounts were provided, including a statement from the resident's roommate suggesting the injury may have occurred while the resident was interacting with her overbed table. Despite facility policy requiring a timely and thorough investigation of all injuries of unknown source, including interviews with all involved persons and witnesses, the facility did not conduct or document such an investigation. The DON confirmed that no staff or resident interviews were performed, no witness statements were collected, and no staff education was completed regarding the incident. Additionally, the resident's roommate reported that staff did not ask her any questions about the injury, even though she had information about the resident's activities at the time. The facility's failure to follow its own abuse investigation policy resulted in a lack of documentation and assessment regarding the cause of the injury.