Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident was found with bruising to the face, including the forehead, right eye, bridge of the nose, and under the left eye, and was sent to the emergency department for evaluation. The facility's policy required a detailed investigation, including obtaining statements from the victim, suspects, and witnesses, as well as securing physical evidence and filing an incident report. However, there was no completed investigation on file, no witness statements, and no investigation notes available for review. Interviews revealed that staff present at the time of the incident could not recall any disputes or events leading to the injury, and some staff involved were no longer employed at the facility. The administrator confirmed the absence of required documentation related to the investigation. The facility did file an initial report with the state health department and notified Adult Protective Services, but the lack of a thorough and documented investigation was identified as a deficiency.