Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who was found with significant bruising to the sternum, right breast, and under the right arm, accompanied by pain and limited range of motion. The resident, who required a sit-to-stand lift for transfers, was later found to have additional bruising, shortness of breath, chest pain, and a critically low hemoglobin level, necessitating emergency medical intervention for an active arterial bleed. There was no reported fall or clear mechanism of injury, and the bruising was noted to be in areas consistent with the use of the stand lift sling, although staff stated that the lift should not cause such injuries. The facility's investigation into the incident was incomplete. Only four staff interview forms were included in the investigative file, and these forms lacked signatures and did not document whether staff were asked about the cause of the bruising, possible falls, or details about the use of the lift. Interviews with staff revealed that the resident disliked the stand lift and sometimes expressed pain during its use, but no staff could identify a specific incident that led to the injury. The investigation did not include interviews with all staff who worked with the resident during the relevant period, nor did it include a comprehensive review of video surveillance beyond a single activity session. The facility's policy requires a root cause investigation and analysis for injuries of unknown source, including gathering statements from all involved staff and witnesses, as well as a description of the resident's behavior and environment at the time of the incident. However, the investigation did not meet these requirements, as it failed to determine the cause of the injury or rule out abuse, and did not document a thorough review of all possible contributing factors or staff involvement.