Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident who was transferred to the emergency department and subsequently to a tertiary hospital, where a CT scan revealed internal bleeding. Nursing notes indicated that the resident had not experienced any documented falls or incidents in the 24 hours prior to the injury, and the last recorded fall occurred several days earlier without head trauma. Despite being informed by the resident's family that the hospital identified a new head bleed possibly due to an unwitnessed fall, staff did not initiate an incident report or conduct an investigation into the cause of the injury. Interviews with facility staff, including the LPN, DON, and Administrator, confirmed that no written investigation or report to the state agency was completed regarding the injury. The facility's own policies require that all accidents and incidents, including injuries of unknown origin, be reported, investigated, and documented, but these procedures were not followed in this case. The Administrator, who serves as the facility's Abuse Coordinator, acknowledged that the incident should have been identified and investigated as an injury of unknown origin, but this was not done.