Failure to Prevent and Investigate Resident Injury of Unknown Origin
Penalty
Summary
The facility failed to prevent an injury of unknown origin to a resident and did not determine the cause of the injury. The resident, who had a history of stroke with hemiplegia, unsteady gait, and multiple psychiatric diagnoses, was found with swelling and discoloration to the left eye, bruising to the chest and right leg, scratches to the face and chest, and complaints of chest pain. These injuries were identified by emergency room staff after the resident was transported to the hospital for agitation. Staff interviews revealed that the resident had been involved in altercations with staff, including throwing rubbing alcohol and physically assaulting staff members, but no staff member reported witnessing or causing the injuries observed. Multiple staff members described escalating behavioral incidents involving the resident, including verbal and physical aggression. The nurse and assistant administrator intervened and monitored the resident after the incidents, but neither reported any visible injuries prior to the resident's transfer to the hospital. The nurse did not report the injury of unknown origin to the administrator as required by the facility's abuse policy. The resident later claimed that staff had assaulted him, but staff denied any physical altercation resulting in injury. The resident's medical record indicated minimal risk for aggression in prior assessments, with only one previous note of physical aggression months earlier. The facility's abuse policy required prompt reporting of suspicious injuries, but this protocol was not followed. The origin of the resident's injuries remained undetermined, and the facility did not take appropriate steps to investigate or report the injuries as required.