Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who was found with discoloration on the right side of the forehead. The resident had a history of metabolic encephalopathy, depression, and generalized muscle weakness, and was assessed as having severely impaired cognitive skills and lacking capacity to make decisions. When the discoloration was discovered by a CNA and reported to an LVN, the LVN did not recall informing the DON or the Administrator. The LVN acknowledged that such an injury should have been reported to allow for a proper investigation. Interviews with nursing staff and facility leadership revealed that, although some staff were aware of the injury, a comprehensive investigation was not conducted. The DON interviewed nurses about possible falls or combativeness but did not explore other potential causes, such as being struck by another resident or staff member. The Administrator did not recall being informed at the time and did not initiate a formal investigation, only making informal inquiries with nurses. The facility's policy required thorough investigation of all injuries of unknown origin, but this was not followed, resulting in the facility being unaware of the cause of the resident's injury.