Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to identify and thoroughly investigate an injury of unknown origin for a resident who was dependent on staff for all activities of daily living due to chronic pain, vascular dementia, and multiple amputations. The resident was re-admitted to the facility following a lengthy hospitalization and was noted to be bed bound, requiring total assistance from staff. During a subsequent hospital visit, the resident was found to have a nondisplaced distal radius fracture, as confirmed by x-ray findings in the hospital records. Family members and staff interviews indicated that the resident had been in pain and exhibited swelling in the affected arm, but the source of the injury was not clear, and the resident was unable to communicate the cause due to cognitive and language barriers. Despite the presence of hospital records in the facility's incident investigation folder that documented the injury, the facility did not address or investigate the injury of unknown origin in its report to the State Agency or as part of its internal investigation. The Director of Nursing and the Nursing Home Administrator both confirmed that they were unaware of the fracture documented in the hospital records, and the hospital x-ray findings were not fully reviewed by the facility's medical director or administration. The facility's investigation focused on allegations of neglect and abuse but did not include a review or investigation of the resident's wrist injury, even though the resident was entirely dependent on staff for care and unable to self-inflict such an injury. The facility's abuse policy required a timely, thorough, and objective investigation of all alleged violations, including injuries of unknown source, and mandated reporting to the State Agency. However, the investigation did not identify or address the injury, did not include a review of all relevant medical records, and did not determine the cause or extent of the injury. As a result, the injury of unknown origin was not investigated as required by facility policy and regulatory standards.