Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident with kidney failure and dementia, who was totally dependent on staff for care but had intact cognition. The resident's family reported shoulder pain, and subsequent assessment revealed swelling and warmth in the left shoulder, leading to an x-ray that confirmed a partial dislocation. The resident was later sent to the emergency room for further evaluation. Despite the facility's policy requiring immediate and thorough investigation of potential abuse or neglect, the Director of Nursing acknowledged that while an internal investigation was conducted, there was no documentation of interviews with staff or the physician, nor were other residents interviewed regarding their treatment. Additionally, an LPN on duty at the time of the incident was unaware of the cause of the injury or whether an investigation had been completed.