Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who was found with facial discoloration, bruising, and swelling. The incident was first noted by a Geriatric Nurse Aide (GNA) during the night shift, who reported a reddened area and blood on the resident's ear, as well as purple discoloration near the eye. The resident had a private duty aide (PDA) present in the room throughout the night, and there were no reports of a fall or change in condition prior to the discovery of the injury. The initial assessment by nursing staff documented the findings and notified the physician and responsible party, but the cause of the injury remained unknown. The facility's internal investigation included obtaining written statements from six nursing staff and two PDAs, including the one assigned to the resident during the night of the incident. The statements indicated that the last care was provided around midnight with no facial markings observed, and the injury was first noticed around 5:30 AM. The PDA assigned that night initially claimed to have observed the resident throughout the shift and denied any incidents. However, it was later revealed through communication with the agency owner that the PDA had fallen asleep during the shift, contradicting the initial statement. The facility did not obtain statements from other residents, and there was a lack of documentation supporting further investigation or actions taken regarding the PDA's conduct. During interviews with facility leadership, it was clarified that the facility's process for investigating injuries of unknown origin typically included interviewing staff from the previous three days and, if staff involvement was suspected, interviewing other residents. In this case, the facility did not interview other residents, citing the presence of a PDA as a witness, despite the PDA not being a facility employee and later admitting to sleeping during the shift. The facility was unable to provide documentation of further investigation or actions taken in response to the PDA's admission, and the only supporting documentation was an email from the agency, dated several months after the incident, indicating the PDA was removed from overnight duties.