Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its Abuse Prevention and Prohibition policy by not conducting a thorough investigation into an injury of unknown origin for one resident. According to the facility's policy, the Administrator is required to complete a comprehensive investigation following such injuries. In this case, the Administrator was notified of a resident's fractured right arm after an x-ray and initiated an investigation. The investigation included reviewing surveillance footage, which showed the resident ambulating without issue before being assisted into and out of the shower room by a shower aide. The resident was later left seated on her rollator in the hallway. However, the Administrator did not review the footage to determine if the resident was left unattended in the shower room or to observe when the certified nursing assistant entered and exited the shower room. The Administrator viewed the footage at a high speed, which may have resulted in missing critical details, and the footage was no longer available for further review. As a result, the investigation did not fully address whether the resident was left alone in the shower room, failing to meet the facility's policy requirements for a thorough investigation of injuries of unknown origin.