Failure to Thoroughly Investigate Resident Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into injuries of unknown origin sustained by a cognitively impaired resident. After a witnessed fall, which was documented as resulting in no injury, the resident was later found with blood and tissue in his ear, slurred speech, and increased weakness, leading to a hospital transfer. Hospital evaluation revealed multiple injuries, including a right temporal hemorrhagic contusion, right temporal bone fracture, small epidural hematoma, and right hip bruise. The facility's five-day follow-up report to the State Agency did not include all of these injuries, only mentioning the hemorrhagic contusion. The investigation documentation provided by the facility was limited to an event report and statements from the LPN and assigned CNA, as well as phone interviews with eight staff. There was no evidence that the investigation included interviews with other staff who may have cared for or observed the resident during the relevant period, nor was there a review of timecards to confirm 1:1 observation coverage. Additionally, there was no review or identification of missing CNA documentation, such as the Point of Care Report and 1:1 Observation/Monitoring Tool, from the time of the fall through the resident's hospital transfer.