Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an injury of unknown source for one resident. The resident, who had diagnoses including diabetes mellitus, urinary retention, metabolic encephalopathy, bladder cancer, hypertension, and depression, was observed with a bruise covering almost the entire left eyelid. The bruise was first brought to staff attention by the resident's daughter, who noticed it prior to staff awareness. Documentation indicated that the resident was cognitively intact and used a hoyer lift for transfers. Staff and family noted the resident sometimes rested his face against the hoyer sling and had difficulty putting on his glasses, often hitting his face in the process. Despite the facility's policy requiring immediate and thorough investigation of injuries of unknown source, the investigation into the resident's bruise was incomplete. While some staff, such as the LPN/Unit Manager, DON, and a Med Tech, were involved in discussions and provided statements, there was no evidence that all staff who provided care to the resident on the days surrounding the appearance of the bruise were interviewed. The investigation relied on verbal statements and did not include written statements from all relevant staff, nor did it document interviews with all potential witnesses or caregivers who may have had knowledge of the incident. The facility's documentation included notes from nursing staff, the interdisciplinary team, and the resident's representative, but lacked comprehensive evidence of a systematic investigation as outlined in facility policy. The surveyor found that the information provided did not demonstrate a thorough investigation into the cause of the injury, as required by the facility's own procedures for responding to alleged violations, including injuries of unknown source.