Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate and follow up on an injury of unknown origin for one resident who was admitted for short-term skilled rehabilitation and nursing care. The resident, who had a history of atrial fibrillation, stroke, urinary tract infection, hearing loss, and dementia with moderate cognitive impairment, was found by a family member to have a bandage on their arm, which upon removal revealed bruises and a gash. The family member reported not being notified by the facility about how the injury occurred, and there was no documentation in the resident's medical record regarding the incident, treatment, or notification to the physician or responsible party. Review of the resident's electronic medical record and skin assessments showed no documentation of a skin tear or related injury on the arm prior to the family member's discovery. Subsequent skin assessments did note a healing skin tear, but there were no corresponding incident or accident reports, progress notes, or treatment orders. The facility administrator confirmed that there were no incident or accident reports or investigations related to the injury, and the unit manager, upon review, was unable to find any documentation or explanation for the injury in the medical record. Interviews with facility staff, including the unit manager and administrator, revealed that the expected process for investigating such injuries—completing a nursing assessment, incident report, notifying the physician and responsible party, and implementing treatment orders—was not followed in this case. The facility's abuse policy requires thorough investigation and documentation of all injuries of unknown source, but this was not completed for the resident's skin tear, resulting in a failure to respond appropriately to an alleged violation.