Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to conduct a thorough investigation of an injury of unknown source for one resident with severely impaired cognition, memory, and decision-making abilities. The resident was found with a bruise and small abrasion on the forehead by an LPN, who documented that the resident denied abuse or neglect but was unable to recall the incident. The investigation consisted only of a statement from the LPN, notification of the provider and the resident's son, a skin check, and monitoring of the bruise. No neurological assessment was performed despite the unwitnessed head injury, and there was no follow-up with the son regarding the time frame or circumstances of the injury. Additionally, the investigation did not include statements from potential witnesses, other staff, or residents who may have had relevant information. Interviews with facility staff revealed that the process for investigating such incidents was not fully followed, as no additional data gathering or witness statements were obtained. The Director of Nursing acknowledged that the investigation was incomplete and lacked thorough data collection as required by facility policy.