Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of injury of unknown origin for one resident. According to the facility's Abuse Prevention Policy, injuries of unknown source require a comprehensive investigation, especially when the injury is suspicious due to its extent, location, or frequency. In this case, the resident was transported from the facility to a dialysis center without any apparent injury, but later developed a bleeding scalp laceration and was sent to the emergency room, where he was diagnosed with a subarachnoid hemorrhage and subsequently died. The facility's investigative summary concluded that there was no substantiated evidence the injury occurred at the facility. However, there was no documentation that the facility obtained critical information necessary for a thorough investigation, such as the emergency room medical record, the County Sheriff's report, the supplemental report from the Sheriff's Department Investigator, or statements from the dialysis clinic. The facility relied on the County Investigator to gather information from the dialysis clinic and did not pursue further contact or visit the clinic after initial attempts to reach them by phone were unsuccessful. Interviews revealed that the facility administrator did not follow up in person with the dialysis clinic or persistently seek out the necessary records and reports. The administrator deferred the investigation to the County Investigator and did not obtain the investigator's report, despite being informed it was available for pickup. As a result, there was no evidence of a complete and thorough investigation into the resident's injury of unknown origin, as required by facility policy.