Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving injuries of unknown origin were reported immediately to the administrator and the State Agency, as required by both facility policy and state law. A resident with a history of cerebral infarction, hemiplegia, difficulty walking, and moderate cognitive impairment was found to have swelling on the right hip and dark purple bruising on the right shoulder and arm. The origin of these injuries was unknown, and the resident was subsequently hospitalized with a hematoma and pneumothorax requiring a chest tube. Despite the facility's policy mandating immediate reporting and investigation of such injuries, there was no documentation of a risk management investigation or notification to the Nursing Home Administrator or State Agency. Interviews with facility staff, including a Registered Nurse/Nurse Manager and the Director of Nursing, confirmed that the expected procedure would have included an assessment, provider notification, investigation, and documentation in risk management. Both staff members acknowledged that this process did not occur for the resident in question. The Nursing Home Administrator also confirmed that the injuries should have been classified as of unknown origin and reported accordingly, but this was not done.