Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for two residents, as required by its own policies and federal regulations. In the first case, a resident returned from an acute care hospital and was noted to have a swollen, warm left knee, with subsequent imaging revealing a femoral fracture. The resident later also complained of wrist pain, which was found to be an acute angulated right distal radial fracture. Although the facility's 5-day investigation follow-up indicated that interviews were conducted with staff, the resident, and a family member, there was no written documentation to support that these interviews took place. Additionally, the clinical record lacked evidence that the injury was noted in the emergency department, and the facility was unable to determine whether the injuries occurred in the facility or during the hospital stay. In the second case, another resident sustained a large hematoma near the left eye, with no known history of a fall at the time of the incident. The facility's report later noted that the resident had an unwitnessed fall prior to the bruise being noticed, but the bruise was not observed during the initial assessment following the fall. The resident also exhibited increasing confusion and an unsteady gait. The facility's follow-up documentation did not provide evidence of a thorough investigation into the injury of unknown origin. The LTC Unit Manager confirmed that comprehensive investigations were not conducted for these incidents and acknowledged a lack of familiarity with the required follow-up procedures.