Failure to Investigate and Report Injury of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source sustained by a resident, as required by policy and regulation. On the day of the incident, a staff member observed a significant burn on the resident's leg when the resident came to the dining room for a scheduled activity. The staff member immediately sent the resident upstairs and noted that the injury could not have occurred in the patio area. Despite this observation, the staff member was not interviewed about the incident at the time, and no immediate investigation was initiated. A registered nurse on duty at the time recalled seeing the injury when the resident was brought upstairs and provided initial wound care. She reported the injury to the incoming nurse and the DON before leaving her shift. The wound was later evaluated by a wound care physician, who determined it to be a full-thickness burn with severe pain and significant size. Despite the seriousness of the injury and the facility's policy requiring immediate investigation and reporting of injuries of unknown origin, the DON stated she was not notified of the injury and no investigation or report to the State was made at the time. The facility's policy defines injuries of unknown source as potential abuse and mandates immediate investigation and reporting. However, the administrator and DON both confirmed that the injury was not reported or investigated as required. The resident involved had multiple complex medical conditions, including diabetes, heart failure, and chronic kidney disease, and was noted to have severely impaired cognitive skills, making thorough investigation and protection particularly important. Documentation showed that the injury was only reported to the State and investigated after the issue was raised during the survey.