Failure to Prevent and Identify Injury of Unknown Origin in Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent an accident resulting in a physical injury of unknown origin to a resident who was totally dependent on staff for care. The resident, a male with a history of toxic encephalopathy, dementia with psychotic disturbance, CVA, and other complex medical conditions, was found by a family member to have a swollen and outwardly turned finger. The injury was later diagnosed as a mildly displaced fracture of the fourth proximal phalanx. The resident was non-verbal, had severely impaired cognition, and required total assistance for all activities of daily living, including transfers and mobility, and was always incontinent. He was also noted to have a history of behavioral symptoms and impaired communication, making it difficult for him to express needs or report incidents. On the morning of the incident, multiple staff members, including CNAs and a medication aide, provided care and assistance to the resident. All staff interviewed stated that they did not observe any swelling or injury to the resident's hand during their interactions, including during transfers from bed to wheelchair and while administering medications. The resident was described as compliant with care during these interactions. The injury was only discovered when a family member visited and noticed the swelling, prompting further assessment and eventual transport to the hospital, where the fracture was confirmed. Staff and facility leadership were unable to determine how or when the injury occurred, and no staff could provide an explanation for the cause of the fracture. The facility's failure to identify, prevent, or explain the cause of the resident's injury, despite the resident's total dependence on staff and inability to communicate effectively, constitutes a lack of adequate supervision and failure to ensure a safe environment free from accident hazards. The incident raised concerns of possible abuse or neglect due to the unexplained nature and type of injury, as well as the lack of timely recognition by staff. The facility's own policies prohibit abuse, neglect, and exploitation, and require prompt identification and investigation of injuries of unknown origin, but these measures were not effective in this case.