Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy by not initiating and thoroughly investigating an injury of unknown origin for a resident who was dependent on staff for all activities of daily living (ADLs) and unable to communicate verbally. The resident, who had a complex medical history including epilepsy, cerebral palsy, pressure ulcers, a history of falls, and was frequently incontinent, was found by a family member to have a black eye and bruising around the left eye. The family member reported the injury to staff, but the administrator stated that staff had witnessed the resident hitting her head on the table, attributing the injury to self-harm. However, the family member disputed this explanation, stating the resident did not have such behaviors. Further investigation revealed inconsistencies and lack of documentation. The Director of Nursing (DON) indicated that an activity aide reported the incident to a nurse, but the nurse did not document the event or complete a risk management report at the time. The DON later completed the risk management documentation days after the incident. Interviews with staff who worked with the resident around the time of the injury showed that none witnessed the resident hitting her head, and there was no progress note or assessment documenting the injury. The facility's abuse prevention policy required all incidents, including those of unknown origin, to be documented and investigated, but this was not followed in this case.