Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who was readmitted with multiple diagnoses, including acute respiratory failure, kidney failure, hypertension, and diabetes. The resident was sent to the hospital after refusing food and fluids and was found to have a new left femoral neck fracture, which required surgical intervention. The resident's family requested an investigation into the cause of the fracture, as there was no documentation of a fall or incident at the facility, and it was unclear if the injury occurred during care or another activity. The Director of Nursing (DON) assumed the fracture was old, referencing a four-year-old record of a different fracture, and did not contact hospital staff to clarify the nature of the injury. The DON also did not interview all staff or therapists who had cared for the resident during the relevant period. The facility's incident report inaccurately described the fracture as old, despite hospital records indicating it was new. The facility's abuse investigation policy requires interviews with all staff present during the period of the allegation, but this was not followed.