Failure to Investigate and Document Skin Injury Incident
Penalty
Summary
The facility failed to thoroughly investigate and document a skin injury incident involving a resident with multiple medical conditions, including rheumatoid arthritis, gait abnormalities, and hemiplegia following a stroke. The resident, who had moderate cognitive impairment, sustained a skin tear on her right lower leg after being transferred from a chair to bed by CNAs. The incident was reported by the resident, who stated her leg got caught under the bed during the transfer. The initial documentation lacked detailed accounts from the CNAs involved, and there was no record of the exact time or comprehensive circumstances of the event, aside from it occurring after returning from the dining room. Interviews with the DON, ADON/Risk Manager, and Unit Manager revealed that no statements were obtained from the CNAs involved, and there was no documentation of the investigation process or findings. The Unit Manager could not recall the incident in detail and did not document the information gathered during her investigation, such as the transfer technique used or the number of staff involved. The facility's policy required obtaining detailed statements and performing an initial investigation to determine the cause, but these steps were not followed. The wound from the incident remained unresolved and continued to require physician-ordered care.