Failure to Implement Abuse and Neglect Policy for Injury of Unknown Origin
Penalty
Summary
Facility staff failed to implement the abuse and neglect policy for a resident with severe cognitive impairment and total dependence for activities of daily living, who was found with an injury of unknown origin. The resident, who had multiple diagnoses including dementia, malnutrition, and osteoporosis, was discovered by an RN to have a black and blue area on the chest. Despite this finding, there was no evidence that the required notifications to the physician or resident representative were made, nor was there documentation of an investigation into the injury as required by facility policy. Interviews with facility staff, including the administrator, CNA, LPN, and ADON, revealed a lack of follow-through on the established procedures for reporting and investigating unexplained injuries. Staff confirmed that any new injuries or changes in condition should be immediately reported to the nurse, and that injuries of unknown origin, especially in nonverbal residents, should be reported to the physician and family and investigated for possible abuse or neglect. However, the administrator was unable to provide any investigation records related to the injury, and the ADON could not find documentation of immediate notifications or an incident report in the resident's record. A review of facility policies confirmed that all unexplained injuries, including bruises and injuries of unknown source, must be investigated, documented, and reported to the appropriate parties. The policy also requires modification of the care plan to prevent recurrence. In this case, the facility did not follow its own procedures for reporting, investigating, and documenting the injury of unknown origin, resulting in a failure to protect the resident as required by policy.