Failure to Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged violation involving a resident who sustained a spiral fracture of the left tibia. Nursing progress notes indicated that the resident was found with pain, swelling, and redness in the left lower extremity, which was later diagnosed as a minimally displaced spiral oblique fracture. The injury was considered of unknown source, as the cause could not be explained by the resident and was not observed by staff. Despite the seriousness of the injury, the facility did not follow its own policy requiring a comprehensive investigation of such incidents. Interviews revealed that the Director of Nursing did not interview any Licensed Nursing Assistants (LNAs) who had cared for the resident on the days leading up to the discovery of the injury. One LNA reported that the resident had expressed pain during a transfer and had been kept in bed due to leg pain, but was not interviewed or asked to provide a statement regarding the injury. The facility's policy mandates that all nursing department witnesses and suspects be interviewed and their statements recorded, but this was not done, and the cause of the fracture was not identified.