Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an alleged injury of unknown origin for a resident with multiple sclerosis and non-Alzheimer's dementia, who was dependent on staff for all activities of daily living and used a Hoyer lift for transfers. The resident was rarely or never understood and unable to communicate how the injury occurred. A family member noticed a dark red bruise wrapping around the resident's lower left leg, which appeared to resemble hand prints, and reported it to staff. The LPN notified the physician and initiated monitoring, while the DON assessed the bruise and attributed it to the resident's legs resting on the wheelchair pedals, implementing a new intervention to place a pillow for protection. However, there was no documentation of interviews with staff or a thorough investigation into the cause of the injury, as required by the facility's abuse policy. Staff interviews revealed that the DON did not believe an injury of unknown origin report was necessary and did not follow the abuse policy, failing to conduct or document interviews with staff who provided care to the resident. The LPN spoke with two CNAs who denied causing the injury, but this was not formally documented as part of an investigation. Observations showed the resident was unable to answer questions about the bruise, and staff were unaware of the new intervention to protect the resident's legs. The facility's policy required a thorough investigation of all alleged violations, including injuries of unknown source, but this was not completed in this case.