Failure to Conduct Thorough Investigation of Resident Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury sustained by a resident, as evidenced by incomplete documentation and inconsistent accounts regarding the cause of the injury. The initial self-report indicated that a resident was found with bruising to the left eye, and the GNA who provided care stated the resident had poked themselves in the eye. However, subsequent investigation reports referenced a fall during a transfer as the cause of injury, with two GNAs reportedly corroborating this account, but without clear identification or statements from these staff members. There was also a lack of documentation explaining the discrepancy between the initial and final accounts of the incident. Further review revealed that the facility did not complete a comprehensive assessment of the resident when the injury was first identified, nor was there evidence of an assessment of other residents on the same assignment. The investigation documentation lacked interviews with other staff or residents who may have witnessed or been aware of the incident. Additionally, there was no documentation in the medical record to confirm that a fall had occurred prior to the resident's transfer to the hospital, nor was there evidence that a comprehensive assessment was completed after the facility became aware of the fall. The resident's care plan and medical record showed inconsistencies regarding the level of assistance required for transfers and ambulation, with some documentation indicating a need for two-person assist and others indicating hand-held assistance. The facility also failed to update the care plan to reflect changes in the resident's status or with each MDS assessment. There was no evidence of staff abuse training or education related to RAI documentation in the investigation materials. These deficiencies were acknowledged by the Nursing Home Administrator during the surveyor's review.