Failure to Thoroughly Investigate Resident Injuries of Unknown Origin
Penalty
Summary
Heritage Ridge Senior Living at Windy Hill was found noncompliant with federal and state regulations regarding the development and implementation of abuse and neglect policies. The facility failed to thoroughly investigate injuries of unknown origin for a resident. Specifically, after a resident was admitted, nursing documentation showed that staff discovered a bruise on the resident's inner thigh, but the facility's investigation only included a single witness statement from the nurse aide who found the bruise. The resident was unable to explain how the bruise occurred. No further statements or evidence of a comprehensive investigation were documented. Later, the same resident was found to have a large bruise on the left shoulder and back during evening care. The facility's investigation into this incident included only two witness statements from the nurse aides who discovered the bruise, with no additional staff statements or documentation of staff education. The resident again could not recall how the injury occurred. The Nursing Home Administrator confirmed that the investigations were not thorough, and there was a lack of evidence to rule out abuse or prevent further injuries.
Plan Of Correction
Attempts were made to collect additional investigative statements on resident #12's without success, and education was provided to the nursing staff on this situation. A review of incident reports since the transition to our current company was completed for accuracy and investigation completion for educational purposes to the staff. Education based on the incidents review was conducted as well as the facility policies content was explained to ensure clinical, and non-clinical staff are aware as well as staff in general of the need and necessity to report these matters immediately and the need for thorough statements from anyone with knowledge of such situations and incidents. Audits will be performed on incident reports requiring follow-up and investigation on a weekly basis for 1 month and bi-weekly for 3 months thereafter. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.