Failure to Investigate Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to conduct a complete investigation into an injury of unknown origin for a resident with hemiplegia, hypertension, and diabetes. The resident, who was cognitively intact but required extensive assistance for self-care and mobility, was found with discoloration around the left eye. Documentation shows that the LPN was notified of the injury, assessed the resident, and informed the responsible party and APRN, who ordered diagnostic tests and interventions. However, the required investigative process, including obtaining statements from all staff who worked with the resident in the previous 72 hours and from the resident, was not completed as per facility policy. Interviews with the LPN, RN Supervisor, and DNS confirmed that no staff or resident statements were collected to determine the cause of the injury. The RN Supervisor acknowledged not assessing the resident or initiating the investigation, and the DNS confirmed that statements should have been obtained but could not provide a reason for the omission. Facility policy mandates timely investigation and collection of staff statements for injuries of unknown origin, but this protocol was not followed in this case.