Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential abuse involving a resident who sustained an injury of unknown origin. According to the facility's policy, investigations should include interviews with all pertinent parties and written, signed statements from those involved, if possible. The resident in question, who had a moderate cognitive impairment and multiple medical diagnoses, experienced an unwitnessed fall and was initially assessed as having no injuries. Three days later, the resident reported pain, and a subsequent X-ray revealed a right femoral neck fracture. The facility's follow-up documentation indicated that only verbal interviews were conducted with staff, and no written statements were obtained. Additionally, there was no evidence that all staff who worked with the resident during the relevant period were interviewed or provided statements regarding the resident's pain and injury. The Director of Nursing and the Administrator, who was also the Abuse and Neglect Coordinator, confirmed that the investigation did not include written staff interviews, citing the length of written statements as a reason. The DON also acknowledged that pain levels should have been documented in the medical record, but a review of the electronic medical record showed no documentation of pain for the resident from the time of the fall until the injury was discovered. The lack of comprehensive interviews and documentation failed to meet the facility's policy requirements for investigating allegations of potential abuse and injuries of unknown origin.