Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident with severe cognitive impairment and a history of Alzheimer's disease and dysphagia. The resident was dependent on staff for mobility and required assistance with activities of daily living. The care plan indicated the resident had impaired cognition and limited physical mobility. During routine rounds, staff discovered bruising on the resident's left arm and shoulder, and the medical director was notified, resulting in discontinuation of a blood thinner and therapy orders. Subsequent documentation showed that the resident had decreased mobility and, later, a protrusion within the bruised area on the left shoulder, which caused pain. The resident was medicated for pain and then transported to the hospital, where a fractured clavicle was diagnosed. Despite these findings, no new incident report or investigation was initiated for the injury of unknown origin. Staff interviews revealed that the presence of a previous bruise led to the assumption that the new injury was related, and therefore, no further investigation was conducted. There was also no Registered Nurse assessment at the time, as none were on duty. Interviews with facility staff, including LPNs, the DON, and the Administrator, confirmed that an investigation was not started because the injury was considered part of a previously investigated bruise. The facility's policies required investigation of all injuries of unknown origin, but this was not followed. The Medical Director stated that an investigation should have been completed for such an injury. The lack of a thorough investigation was contrary to facility policy and regulatory requirements.