Failure to Investigate Injury of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and total dependence for activities of daily living. The resident, who had multiple diagnoses including dementia, malnutrition, and osteoporosis, was found to have a black and blue bruise on the chest by an RN, who documented the finding and noted intent to notify the nurse practitioner. However, there was no evidence that a comprehensive investigation was initiated or completed regarding the injury. Interviews with facility staff, including the administrator, CNA, LPN, and ADON, confirmed that the facility's policy requires immediate investigation and notification of the physician and resident representative for injuries of unknown origin. Despite these policies, the administrator was unable to provide any documentation of a Facility Reported Incident or investigation related to the injury. The facility's own policy outlines specific steps for investigating alleged abuse or neglect, but these procedures were not followed in this case.