Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure a thorough investigation of an injury of unknown origin for one resident. A bruise was discovered on the resident's left forearm, and initial interviews were conducted with the Certified Nursing Assistant (CNA) who found the bruise and the Registered Nurse (RN) who assessed it. The resident, who is severely cognitively impaired, provided inconsistent accounts of how the bruise occurred, at times referencing bumping into a transfer device or a dresser drawer, but was unable to recall specific details. The facility's investigation included interviews with the resident, CNA, and RN, as well as interviews with other residents on the unit. However, the facility did not interview or obtain statements from all staff members who had worked with the resident during the shifts prior to the discovery of the bruise. Staff schedules indicated that additional CNAs were present during the relevant timeframe, but their input was not sought as part of the investigation. The facility's self-report and documentation did not reflect a review of staff schedules or comprehensive staff interviews to determine if any staff had observed the bruise earlier, witnessed the incident, or had information about transfers involving the resident. The facility's policy requires that all injuries of unknown origin be immediately and thoroughly investigated to rule out abuse. Despite this, the investigation was limited in scope and did not include all potentially relevant staff. The deficiency was identified when the surveyor noted the lack of comprehensive staff interviews and the absence of a full review of staff schedules in the facility's investigative process.