Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of an injury of unknown origin involving a resident who sustained a fractured tibia and fibula, requiring hospitalization and surgical intervention. The facility's policy required immediate reporting and thorough investigation of all injuries of unknown origin, but the investigation into this incident was incomplete and contained several discrepancies. The resident, who had severe cognitive impairment and required substantial assistance for transfers and activities of daily living, was found in her wheelchair complaining of leg pain, and was later diagnosed with significant fractures. The investigation relied on staff interviews and video surveillance, but the video did not capture the inside of the resident's room, and the timeline established by the facility was inconsistent with staff statements. Staff provided conflicting accounts regarding who assisted the resident into bed after the injury, and their descriptions of the incident changed after a reenactment conducted several days later. The facility did not clarify these discrepancies or document how the final conclusion about the cause of injury was reached, especially as the initial and reenacted scenarios differed significantly. Additionally, the facility failed to conduct thorough and relevant interviews with other residents, including the resident's cognitively intact suitemate, who may have witnessed or overheard the incident. The interviews conducted were generic and did not address specific concerns about the care provided by the staff involved in the incident. Language barriers between the DON and the staff involved further contributed to unclear communication and possible misunderstandings during the investigation, which were not adequately addressed or clarified in the documentation.