Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown source for one of four sampled residents, as required by its own policy and procedure. The resident in question was admitted with multiple diagnoses, including a right thighbone fracture, aftercare following right hip surgery, Parkinson's disease, and dementia. Upon review of the resident's records, it was found that shortly after admission, the resident experienced pain and discomfort in the hip, which led to an x-ray revealing a right hip dislocation. The resident was subsequently transferred to a general acute care hospital for further evaluation. During interviews, the DON acknowledged that staff did not know how the resident sustained the hip dislocation and admitted that no investigation was conducted, mistakenly believing the injury had occurred prior to admission. The facility's policy, however, clearly states that injuries of unknown origin are to be reported and thoroughly investigated, with the administrator responsible for initiating such investigations. Both the DON and the administrator confirmed that the required investigation was not performed in this case.