Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure a complete and thorough investigation of an injury of unknown origin for one resident. Clinical record review showed that the resident, who was known to transfer herself and wander with poor safety awareness, was observed with a 5 cm by 4 cm purple bruise on the top of her right breast. The resident was unable to explain how the bruise occurred. The facility's investigation included an assessment and measurement of the bruise, and an interdisciplinary team reviewed the incident, noting the resident's habit of carrying large pitchers of drinks on her chest, which was considered consistent with the injury. Abuse was ruled out based on this information. However, the investigation only included two staff witness statements: one from a nurse aide who observed the bruise and one from an LPN who was informed of the bruise by a registered nurse. The Director of Nursing confirmed that no further investigation was completed, despite facility policy requiring statements from all staff assigned to the resident and any staff with direct knowledge of the incident on the three shifts prior to discovery, unless a cause was identified. The lack of a comprehensive investigation into the injury of unknown origin constituted a deficiency.