Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident, resulting in a deficiency related to abuse prevention and reporting. The resident, who was cognitively impaired with a BIMS score of 6/15 and multiple significant medical diagnoses including vascular dementia and chronic kidney disease, was observed with a dark, faded area on her left cheek. The care plan noted a skin tear on the resident's face and documented that the resident had accused staff of hitting her. Despite this, there was no evidence that an investigation was initiated to determine the cause of the injury or to rule out abuse, as required by facility policy. Interviews with the Unit Manager and wound care nurse confirmed that the injury was observed and treated, but no one could explain how the injury occurred. The Acting DON and the administrator both acknowledged that no investigation had been conducted, and the administrator confirmed that the incident should have been investigated and reported to the state agency. The facility's policy mandates prompt and thorough investigation of injuries of unknown origin, but this was not followed in this case.