Failure to Investigate Resident Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate the cause of a right arm fracture sustained by a resident with cognitive communication deficits and muscle weakness. The resident was observed with a contracted right hand in a sling and was unable to explain the source of the injury. The resident's medical record indicated a transfer to a general acute care hospital for evaluation and treatment of the fracture, but there was no documentation in the nursing or progress notes regarding how the injury occurred. Interviews with the Assistant Director of Nursing and the Social Worker confirmed that there was no documented evidence of an investigation into the injury of unknown origin. The facility's policy on abuse, neglect, and exploitation requires immediate investigation of injuries from unknown sources, but this was not followed in this case. The lack of investigation was verified by both staff members during record reviews and interviews.