Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate and respond appropriately to an injury of unknown origin for one resident who was observed with discoloration on her forehead, a black eye, and eye swelling. The resident, who had diagnoses including chronic kidney disease, dementia, and schizophrenia, was dependent on nursing staff for most activities of daily living and lacked capacity to make decisions. On the morning of the incident, a CNA observed the discoloration, and the resident's physician and family were notified. Orders were given for a skull x-ray, skin monitoring, and neurological checks, but no investigation was initiated to determine the cause of the injury or to rule out abuse or neglect. Interviews with nursing staff and the DON confirmed that the injury was unwitnessed and that no formal investigation was conducted, despite facility policy requiring immediate investigation of injuries of unknown source. The facility's policies also required reporting such incidents to appropriate authorities and conducting thorough investigations, including interviews with staff and residents. The lack of investigation into the resident's injury constituted a failure to follow these policies and procedures.