Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who was sent to the hospital with swelling and pain in the left hip. The resident, who had diagnoses including Alzheimer's disease, hypertension, and pneumonia, required significant assistance with activities of daily living and had no documented open areas or bruises prior to the incident. Upon transfer to the hospital, staff there identified second-degree burns with blistering on both hands and the thigh, which had not been previously documented or reported by facility staff. Interviews revealed that the charge nurse on duty was focused on the resident's leg pain and swelling and did not assess or document the skin changes, specifically the blister on the left hand, which was only noticed by a CNA and an LPN as the resident was being transferred. Neither the charge nurse nor the LPN documented the blister or reported it to the Director of Nursing (DON). The DON, upon being notified by the hospital, stated she was unaware of how the burns occurred and had not interviewed nurse aides as part of the investigation, despite facility policy requiring comprehensive investigation and documentation of injuries of unknown origin. The administrator acknowledged that staff failed to report the skin changes prior to the resident's transfer, which prevented an investigation from being initiated. Facility policy required that all changes in a resident's condition, including skin injuries, be reported, assessed, documented, and investigated to determine the cause, but these steps were not followed in this case.