Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that injuries of unknown origin were thoroughly investigated for two residents who sustained skin tears. For one resident with Alzheimer's Disease, documentation showed the presence of two new skin tears on the left upper extremity, with the resident unable to explain their origin. Record review did not reveal any evidence that an investigation was conducted to determine how these injuries occurred. During an interview, the Director of Nursing Services (DNS) acknowledged the lack of an investigation and confirmed that one should have been initiated. Similarly, another resident with chronic kidney disease sustained a 1-centimeter skin tear to the left knee, with the progress note lacking any explanation for the injury's origin. Further review of records did not show that an investigation was conducted to determine the cause of the skin tear. Interviews with both a Licensed Practical Nurse and the DNS confirmed that the documentation did not include the origin of the injury and that no investigation had been performed.