Failure to Promptly and Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a prompt and thorough investigation into an injury of unknown origin for one resident. The resident, who was cognitively impaired and dependent for transfers, experienced a syncopal episode and was transferred to the ER. Later, the responsible party reported that EMS had not been gentle during the transfer, and the resident had cried out in pain. However, the facility's investigation lacked documentation of staff witness statements, did not include a record of conversation with the responsible party prior to the injury, and did not provide supporting documentation for the conclusion that the fractures were pathological. The investigation summary listed possible causes, including a pathological process, seizure activity, or rough EMS transfer, but did not contain comprehensive evidence or interviews to support these conclusions. The injury, specifically bilateral femoral neck fractures, was not identified until a later hospital visit for evaluation of seizure-like activity. Progress notes indicated facial bruising without a reported history of trauma, and imaging revealed the fractures may have been subacute. The administrator acknowledged that the investigation was incomplete, as staff were not asked for written statements and there was no information regarding events leading up to the hospital transfer or current hospital documentation. The responsible party also reported that the facility did not provide information about the cause of the injuries during care plan meetings.