Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to complete a thorough investigation and report the results to the State Agency regarding an injury of unknown origin for one resident. According to facility policy, all suspected violations, including injuries of unknown source, were to be reported to the Administrator or designee, and notifications were to be made to the State licensing agency, ombudsman, resident's representative, APS, and the resident's physician within specified timeframes. The Administrator or designee was also responsible for completing an investigation and sending the results to the appropriate agencies within five working days. A resident with severe cognitive impairment, dependent on staff for all activities of daily living, was found to have significant bruising and minimal swelling on the right foot. The facility's investigation suggested the injury may have occurred during a transfer with a mechanical lift, but no staff interviews or evaluations of transfer procedures were conducted to confirm this. The DON and Administrator later confirmed that a thorough investigation was not completed and no report was sent to the State Agency.