Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to complete and document a thorough investigation into an injury of unknown origin for one resident. The resident, who had diagnoses including dementia and brief psychotic disorder and required supervision for most activities of daily living, was observed with a new skin issue—specifically, discoloration and a possible laceration or burn on the forehead. Progress notes indicated that the injury was first noticed by a CNA, and the nurse, physician, wound care, and family were notified. Treatment was ordered, but there was no documentation of a fall or clear cause for the injury. The physician's note referenced an infection or burn and stated that staff reported no fall occurred. Despite these findings, there was no evidence in the Michigan reporting system of an investigation being initiated for this injury of unknown origin. Interviews with the DON and Administrator revealed that neither was aware of the injury at the time it occurred, and as a result, no investigation or reporting to the State Agency was conducted. The facility's own policy requires that all incidents of possible abuse or unexplained harm be investigated, including interviews with involved parties and a root cause analysis. However, these steps were not taken in this case, and the origin of the resident's injury remained unknown and uninvestigated.