Failure to Protect Cognitively Impaired Resident from Injury of Unknown Origin
Penalty
Summary
A cognitively impaired resident with a history of vascular dementia, cerebrovascular disease, and significant physical and cognitive limitations sustained a second-degree burn of unknown origin to the left arm and shoulder. The resident was known to be at high risk for falls, had impaired decision-making, and required substantial assistance with activities of daily living. In the days leading up to the injury, the resident became increasingly combative, resistant to care, and complained of pain, but refused interventions. Documentation in the medical record noted pain complaints and resistance to care, but lacked specific details about the location of pain or the interventions offered. On the day the injury was discovered, multiple CNAs attempted to provide care but were met with combative behavior and were only able to change the resident's brief, leaving other clothing unchanged due to resistance. The resident remained in bed on the left side for an extended period, which was unusual for his baseline activity level. Staff noted the resident was not acting like himself, was in visible distress, and repeatedly complained of pain, particularly in the left arm and leg. When staff were finally able to reposition the resident, they discovered significant skin sloughing and blistering on the left arm, consistent with a second-degree burn. The injury was not present the previous day, and the resident was subsequently sent to the hospital for evaluation. The facility's investigation was unable to determine the cause of the burn. Environmental checks, review of meals and linens, and staff interviews did not reveal any source of hot fluids or environmental hazards. The investigation also noted inconsistent documentation and assessment practices, with staff failing to fully assess or document the resident's complaints of pain and changes in behavior. The lack of thorough assessment and documentation, combined with the resident's cognitive impairment and inability to communicate the cause of the injury, resulted in the resident sustaining a significant injury of unknown origin.