Failure to Conduct Thorough Investigation of Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation following the discovery of an injury of unknown origin for one resident. Review of the resident's progress notes for the specified period showed no documentation of a bruise, and a skin assessment performed by an LPN did not note any injury to the resident's forehead. However, an undated incident report indicated that the resident was found with a bruise of unknown origin on the forehead, and this was reported to the Oklahoma State Department of Health. The facility's policy requires an investigation to determine the cause and effect of any potential abuse or neglect, but this was not fully carried out. Interviews revealed that the administrator did not document interviews with all staff who worked with the resident, and some staff, including the LPN who performed the skin assessment, were not interviewed at all regarding the injury. The administrator acknowledged that documentation of the investigation was lacking, and both the administrator and DON confirmed that the cause and timing of the injury were not determined. The DON also admitted that a thorough investigation was not conducted and that more staff interviews should have been documented.