Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown source for one resident who was admitted with morbid obesity and pressure ulcers. The resident had a urinary catheter placed, and several days later, two new stage three pressure ulcers were discovered on the right thigh near the buttock. The incident report for this event did not include essential investigative steps such as interviews with other residents, audits of other residents with catheters, or interviews with staff who had contact with the resident during the relevant period. Additionally, the report did not rule out abuse or neglect as required by facility policy. Interviews with facility staff revealed that the incident report was incomplete and that responsibility for its completion was not clearly assigned or followed through. The administrator acknowledged that the report was not completed in a timely, accurate, or thorough manner, and that available staff resources were not utilized to assist with the investigation. The director of nursing also stated that they did not participate in the investigation and had delegated the task to another staff member who left it unfinished.