Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident developed multiple skin tears during her stay, including a 2x2 inch skin tear on her left upper arm and a quarter-sized skin tear on her left hand. Family members reported these injuries to staff, with the resident and her family indicating that the injuries may have occurred during transfers or showers, possibly due to rough handling by certified nurse assistants (CNAs). Despite these reports, there was no initial documentation or incident report completed for the skin tears, and staff members interviewed were either unaware of the injuries or did not know how they occurred. Nursing staff, including CNAs and LPNs, demonstrated a lack of awareness regarding the resident's injuries, with one CNA stating she informed a nurse who was unable to address the issue at the time, and the subsequent nurse was unaware of the injury. The facility's regional nurse consultant confirmed that there was no documentation of the skin tear and that an investigation would be initiated only after the surveyor's inquiry. The facility's policy requires that all injuries of unknown origin be reported, documented, and investigated, but this process was not followed in the case of this resident. The final abuse investigation report indicated that the skin tear was ultimately attributed to a CNA accidentally causing the injury during a transfer after a shower, but this was only determined after the fact and not at the time of the incident. The initial lack of documentation, failure to complete an incident report, and delayed investigation represent a failure to respond appropriately to an alleged violation and to follow the facility's own policies regarding injuries of unknown origin.