Failure to Conduct Thorough Investigation of Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to conduct a thorough investigation into an injury of unknown origin sustained by a resident with severe cognitive impairment, dementia, involuntary movements, and osteoarthritis. The resident was totally dependent on staff for all activities of daily living and required two-person assistance for bed mobility and transfers, as documented in the care plan. The resident was found with a swollen, red left thumb, which was later diagnosed as a fracture. The incident was reported as a reportable event, and the responsible party and physician were notified. The investigation initiated by the Director of Nursing Services (DNS) was incomplete. Statements from nurse aides and licensed staff did not identify which staff provided care to the resident during the relevant shifts, nor did they provide details about how care was delivered or whether any unusual occurrences took place. The DNS was unable to determine who provided care to the resident on the day prior to the injury, and some staff could not recall their involvement. Additionally, the DNS did not directly interview all relevant staff, and the investigation lacked documentation and clarity regarding the circumstances of the injury. Medical review revealed conflicting diagnoses regarding the nature of the fracture, with initial suggestions of a pathological fracture due to osteoporosis, but later clarification indicated it was not pathological. The facility's abuse policy requires immediate and thorough investigation of injuries of unknown origin, including identification and interviews of all involved individuals, but this was not followed in this case, resulting in an incomplete investigation.