Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse or neglect involving a resident who was found with a large bruise and skin tears at the base of the neck. The facility's investigation did not include interviews with staff members who had direct contact with the resident on the day the injury was discovered. Instead, statements were obtained from staff who were not assigned to the resident on that day and had no knowledge of the incident. Additionally, the investigation did not include a physical assessment or recreation of the transfer process to determine if the injury could have been caused by the mechanical lift, as was suggested by facility administration. The documentation of the injury was inconsistent, with conflicting dates reported for when the injury was discovered and discrepancies in the number of open areas within the bruise. The bruise itself was not measured or thoroughly described in the medical records. Furthermore, the residents interviewed to assess safety concerns were from different units and floors, and therefore did not interact with the same staff as the injured resident, limiting the effectiveness of the investigation in ruling out potential abuse by staff members involved in the resident's care. The resident involved had significant medical needs, including hemiplegia, moderate cognitive impairment, and was dependent on staff for all activities of daily living, requiring the use of a full mechanical lift for transfers. The facility's investigation summary included a statement that the police were notified, but verification with the police department revealed that no such report was filed. The investigation did not follow the facility's own policy for a comprehensive and prompt investigation of injuries of unknown origin, as required.