Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly and promptly investigate an injury of unknown origin sustained by a resident with multiple medical conditions, including a stable burst fracture of two vertebrae, chronic respiratory failure, chronic lymphocytic leukemia in remission, pain, osteoarthritis, and dorsalgia. The resident, who had moderately impaired cognition and was dependent on staff for transfers, was found with two bruised areas and skin tears on her left lower leg after being assisted by CNAs for supper. The resident reported that her leg was bumped during a transfer, but the care plan did not provide specific staff direction for transfers and mobility, and there was no history of falls since admission. The incident report for the injury did not include a dated witness statement, and the facility was unable to provide a witness statement documenting what happened during the transfer, despite the resident's claim. The facility's policy required all injuries of unknown origin to be thoroughly investigated and documented, but the investigation was incomplete and not conducted in a timely manner. The interdisciplinary team reviewed the incident, but the required documentation and witness statements were missing or undated, resulting in a failure to meet the facility's own policy for investigating potential abuse, neglect, or exploitation.