Failure to Document Thorough Investigation of Injury of Unknown Origin
Penalty
Summary
The facility failed to document a thorough investigation into an injury of unknown origin for one resident with significant cognitive impairment and physical dependency. The resident, who had diagnoses including a displaced femoral neck fracture, dementia, and anxiety disorder, was found with a bruise on the right medial knee/shin. The initial nursing note indicated the bruise was noticed in the dining room, but the event was unwitnessed, and the resident was unable to describe what happened. The facility's incident investigation form noted the injury was not witnessed, and immediate actions included ordering an X-ray and considering changes to table height. However, there was no documentation of staff or resident statements, and the investigation lacked written accounts from those involved or present at the time. Interviews with the DON and staff revealed inconsistencies and gaps in the investigation process. The DON stated that no one witnessed the incident and that he could not locate statements from the nurse or CNA, with the Unit Manager only verbally asking staff about the event without documentation. A CNA reported discovering the bruise during rounds and notifying the nurse, but did not witness the resident hitting her leg. The LPN recalled being informed of the bruise and assessing it, but also did not witness the event and stated that assumptions could not be made. The lack of documented interviews, statements, and a comprehensive investigation process led to the deficiency cited in the report.