Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for two residents. For one resident with memory impairment and behavioral issues such as crawling on the floor and ramming into objects, staff discovered bruising and swelling around the left eye, along with dried blood above the eyebrow. The resident was unable to explain the injury, and no staff witnessed the incident. The investigation consisted only of two CNA interviews, with no further documented attempts to determine the cause. The Director of Nursing confirmed that the cause of the injury was not witnessed and that the resident could not explain it, but did not consider it an injury of unknown origin, despite the lack of explanation or observation of the event. Another resident, who had moderate cognitive impairment and a recent diagnosis of a blood disorder, was found with facial bruising. The resident was unaware of the bruising and could not explain its cause. Staff attributed the bruising to the resident's low platelets and blood disorder, but there was no documentation of the injury in the medical record, nor was there any investigation into the cause. The DON and administrator were not aware of the injury and confirmed that no investigation had been conducted. The facility's policy requires that all injuries of unknown origin be reported and investigated, including interviewing all relevant parties and following the same time frames as for abuse investigations. In both cases, the facility did not follow its policy, as there was insufficient investigation and documentation regarding the injuries of unknown origin for the two residents.