Failure to Immediately Investigate and Protect After Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse and neglect policy when a cognitively impaired resident was found with a bruise and swelling to the left clavicle of unknown origin. The injury was first observed by staff at approximately 12:20 PM, but the LPN/Supervisor did not immediately initiate an investigation as required by facility policy. The resident, who had severe dementia, agitation, a history of falls, and required substantial assistance with activities of daily living, was unable to describe how the injury occurred. The resident was noted to be physically combative and had poor safety awareness, but no immediate action was taken to protect the resident or to remove staff from duty pending investigation. On the following day, the resident complained of pain and had limited range of motion in the left arm. The physician was notified, and an X-ray revealed a closed, displaced fracture of the left clavicle. The Assistant Director of Nursing confirmed that the investigation and staff suspensions were not initiated until the day after the injury was first observed. Staff who had access to the resident continued to work additional shifts after the injury was identified, providing them continued access to the resident and other residents on the unit. Documentation and interviews revealed inconsistencies in staff accounts regarding the provision of care and the discovery of the injury. The facility's policy required immediate reporting, investigation, and protection of residents in cases of suspected abuse or injury of unknown origin. However, the required steps were not followed when the injury was first discovered. The delay in initiating an investigation and in suspending staff placed the resident and others at risk, as staff under investigation continued to provide care. The deficiency was identified as Immediate Jeopardy due to the likelihood of serious harm.
Removal Plan
- An incident report was completed by LPN/S #1 when discoloration was noted to left collar bone.
- The ADON and LNHA initiated an investigation to rule out abuse, the physician was notified, and an X-ray was obtained which revealed a left clavicle fracture.
- The NJDOH and Ombudsman were notified, and the CNA and HA were suspended.
- The President (VP) of Clinical Services and LNHA reviewed the abuse policy with no changes, and the VP of Clinical Services re-educated the DON and the LNHA on the abuse policy.
- The ADON/designee began a facility wide education for all staff on the abuse and neglect policy.
- The Unit Managers and Nursing Supervisors were re-educated on the abuse policy and requirement to report and suspend staff pending the outcome of investigations.