Failure to Immediately Investigate Injury of Unknown Origin and Implement Abuse Policy
Penalty
Summary
The facility failed to immediately implement its abuse and neglect policy when a cognitively impaired resident was discovered with discoloration and minor swelling to the left clavicle, which was later determined to be a fracture. On the day the injury was first observed, the LPN/Supervisor did not initiate an immediate investigation as required by facility policy. Instead, the incident was documented, but no immediate action was taken to suspend staff or begin a thorough investigation to rule out abuse, despite the injury being of unknown origin and the resident being unable to describe how it occurred. The resident involved had severe dementia with agitation, a history of falls, and exhibited frequent physical and verbal behaviors toward others. The care plan indicated the resident required substantial assistance with activities of daily living due to impaired mobility and safety awareness. On the day of the incident, the resident was noted to be physically combative and unable to provide an account of the injury. The LPN/Supervisor documented the findings and notified the nurse practitioner and family, but did not initiate the required abuse investigation or remove staff from duty pending the outcome. It was not until the following day, when the resident complained of pain and had limited range of motion in the left arm, that the physician was notified, an X-ray was ordered, and an investigation was initiated. Staff who had cared for the resident continued to work and had access to the resident and other residents during this period. Interviews with facility leadership confirmed that the abuse and neglect policy was not followed, as the investigation and staff suspensions were delayed until after the injury was confirmed as a fracture.
Removal Plan
- An incident report was completed by LPN/S #1 when the discoloration was noted to the resident's 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.
- The CNAs and HA were suspended.
- The VP of Clinical Services and LNHA reviewed the abuse policy with no changes.
- The VP of Clinical Services re-educated the DON and the LNHA on the abuse policy and investigation.
- 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.