Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate and document an injury of unknown origin for a resident with multiple complex medical conditions, including multiple sclerosis, diabetes, severe cognitive deficit, and dependence on staff for all activities of daily living. The resident was found to have an unstageable pressure ulcer with a conjoined skin tear on the right lateral elbow, but there was no documentation in the medical record regarding when or how the skin tear occurred. Interviews with nursing staff and the Director of Nursing confirmed the absence of documentation and investigation into the origin of the skin tear. Facility policy requires that any injury of unknown origin be assessed, documented, and investigated within 24 hours, including completion of an incident report and notification of the physician and family. Despite these requirements, the medical record lacked evidence of assessment, documentation, or investigation related to the skin tear. The deficiency was identified during a complaint investigation and affected one resident reviewed for pressure ulcers.