Failure to Submit Complete Investigation Report for Injury of Unknown Origin
Penalty
Summary
The facility failed to report sufficient information regarding the results of an investigation into an injury of unknown origin for one resident. According to facility policy, all incidents of abuse, neglect, or injuries of unknown source must be promptly and thoroughly investigated, with a written report of the investigation results and any actions taken submitted to the state survey agency within five working days. However, review of the Incident Reporting System (IRS) and related documentation revealed that the facility did not submit a final investigation report with adequate details describing the results of the investigation or any corrective actions taken. The resident involved had a history of Parkinson's Disease, lack of coordination, muscle weakness, repeated falls, and moderate cognitive impairment. The care plan identified the resident as being at risk for falls, with interventions such as ensuring the call light was within reach and encouraging the resident to call for assistance. On the day of the incident, the resident was found on the floor after calling for help, complaining of pain in the right hip and leg. The resident was subsequently transferred to the emergency room, where a right femoral fracture was identified. Despite the incident being reported in the IRS and a follow-up submission noting the injury, the facility's report to the state agency lacked sufficient information about the investigation process, findings, and any actions taken. The IRS entry for the investigation was left blank, and the follow-up submission contained only a single sentence without details of interventions or investigative outcomes. Interviews with state agency staff and the facility administrator confirmed that a final investigation report was not submitted as required by policy.