Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of an injury of unknown origin for a resident with significant cognitive impairment and multiple medical conditions, including dementia, contractures, and altered mental status. The resident was dependent on staff for activities of daily living and had a history of swelling in both upper and lower extremities. Documentation in the medical record indicated the resident had a midline IV placed in the right arm, and subsequently developed pain, swelling, and an anterior dislocation of the right shoulder, which was confirmed by radiology and led to a hospital transfer. The facility's abuse prevention policy required a thorough investigation of any incident or allegation involving abuse, neglect, or mistreatment, including gathering facts and completing a final report with a conclusion based on known facts. However, the investigation into the resident's injury was incomplete. The facility was unable to provide a written statement from the ADON, statements from nursing staff who provided care to the resident, or evidence of staff education following the injury. Only two statements from CNA staff were included, and the investigation relied heavily on a statement attributed to an RN who later denied having been interviewed about the incident. Interviews with facility staff, including the ADON, RN, and Medical Director, revealed uncertainty about the cause of the resident's shoulder dislocation. The Administrator acknowledged that a more extensive investigation would have provided a clearer picture of the events leading to the injury. The lack of comprehensive documentation, missing staff statements, and reliance on unverified accounts resulted in a failure to meet the facility's policy requirements for investigating injuries of unknown origin.