Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident who was cognitively intact and had multiple complex medical conditions, including a history of fractures. The resident developed new pain and swelling in her left leg, which was initially assessed by nursing staff and led to diagnostic testing, including a Doppler and x-ray. The x-ray revealed a new proximal tibia stress fracture, and subsequent orthopedic evaluation confirmed a new patellar fracture, unrelated to the resident's pre-existing tibia fracture. Despite these findings, the facility's investigation into the injury did not include interviews with therapy staff, who had been informed by the resident's daughter about the increased pain, and the investigation was closed based on the incorrect assumption that the new fracture was an extension of the existing injury. The facility's self-reported incident investigation was officially closed before all relevant information was obtained, and after closure, it was discovered that the initial determination regarding the nature of the fracture was inaccurate. The administrator acknowledged that the investigation should have been reopened to reflect the new information and that therapy staff should have been interviewed as part of the process. The facility's policy required a comprehensive investigation of injuries of unknown source, including interviews with all relevant staff and review of all circumstances, which was not fully followed in this case.