Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin involving a resident with Alzheimer's disease, dementia, and muscle wasting and weakness. The resident was found sitting in a wheelchair with their right leg in an unnatural position, and a fracture was suspected. The resident was transferred to the hospital, where a right hip fracture was confirmed, requiring surgical intervention. The facility's investigation included interviews with all staff members involved in the resident's care and a review of security footage, which confirmed the resident remained in their room throughout the day. However, there was no evidence that any other residents were interviewed as part of the investigation. During interviews, the DON stated that her process for investigating injuries of unknown origin involved reviewing staff schedules and interviewing staff who had contact with the resident. She acknowledged that she did not consider interviewing other residents, even though this could have provided additional information about the incident. The surveyor noted that without interviewing other residents, the facility could not rule out possible abuse or determine whether staff handling may have contributed to the injury. The DON agreed that interviewing other residents would have been an important step in the investigation.