Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of an injury of unknown origin for one resident. The facility's policy required the Nursing Home Administrator or designee to investigate all allegations and interview all persons involved or with knowledge of the occurrence. The resident in question was totally dependent on staff for all activities of daily living and required two staff members for bed mobility. The resident had a history of chronic left shoulder dislocation and was found to have a fractured humerus or scapula with a dislocated right shoulder, as confirmed by hospital records. The injury was reported to the State Survey Agency in a timely manner, and a five-day follow-up summary was provided. However, the facility's internal investigation did not include interviews with potential witnesses or staff who may have had knowledge of the incident. Interviews with the current DON, Clinical Consultant, and Administrator confirmed that no staff interviews or witness statements were collected as part of the investigation. The current abuse coordinator also stated that her process would include gathering witness statements and interviewing any suspects, but this was not done in this case.