Failure to Conduct Thorough Investigation of Injury of Unknown Origin
Penalty
Summary
Facility staff failed to conduct a thorough investigation regarding an injury of unknown origin for a resident with multiple diagnoses, including psychotic disorder, depression, hypertension, anorexia, dementia with behavioral disturbance, and dysphagia. The resident was assessed as having severely impaired cognitive skills and was unable to verbalize the cause of the injuries, which included abrasions on the left forehead and over the right eyebrow. The incident was documented in the clinical record, and the family was notified. The injury was reported to the state agency, and investigation findings were submitted. Upon review, the facility's investigation included written statements from staff who worked after the injury was identified and from one CNA who worked the previous night shift. However, there were no written statements obtained from staff working the shift when the injury was discovered. One statement lacked identifying information such as employee name, job title, or shift worked. Interviews with the administrator and former DON revealed that statements were only obtained from certain shifts, and the facility's policy requiring a thorough investigation, including interviewing all relevant staff, was not followed.