Failure to Prevent and Identify Injury of Unknown Origin in Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent accidents for a resident with severe cognitive impairment and multiple complex medical diagnoses, including traumatic brain injury, Parkinson's disease, and a history of falls. The resident was involved in a witnessed fall from her wheelchair to her knees during a smoke break, after which multiple progress notes documented no visible injuries or skin issues for several days. However, the resident was later found with significant swelling and ecchymosis around the right periorbital area, and increased confusion, which led to her being sent to the emergency room. Hospital records confirmed the presence of a black eye and intracranial hemorrhage, with the injury's origin remaining unknown. Staff interviews revealed that the cause of the resident's injury could not be determined, and there was inconsistency between the observed fall and the resulting injury, as the fall was not witnessed to involve the resident's head. The police investigation and staff statements further indicated uncertainty about how the injury occurred, with no staff able to provide an explanation. The lack of adequate supervision and monitoring, especially given the resident's history of wandering, agitation, and severe cognitive impairment, contributed to the failure to prevent or promptly identify the cause of the injury.