Failure to Protect Resident from Injury of Unknown Origin and Inadequate Incident Reporting
Penalty
Summary
A resident with a history of severe cognitive impairment, psychiatric disorders, and physical limitations sustained unexplained facial injuries, including swelling, hematoma, and contusions extending from the right eye to the corner of the right lip. The injury was first observed by a nurse aide during morning rounds, and the resident was subsequently transferred to the hospital for evaluation. The source of the injury was not witnessed, and the resident, who was severely cognitively impaired, was unable to provide a clear explanation. The resident did, however, repeatedly state the name of a specific staff member when asked about the injury, though details provided by the resident varied over time. Interviews with staff revealed that the nurse aide assigned to the resident during the previous shift had been scratched on the face by the resident during incontinence care, but this incident was not reported to the supervising nurse as required. Other staff who interacted with the resident during the evening and night shifts did not observe any signs of injury or distress prior to the morning when the injury was discovered. The resident's roommate was unable to provide information due to blindness and lack of awareness of the incident. Medical assessments confirmed the presence of traumatic facial injuries, but no fractures were found. The hospital physician noted that the injuries were consistent with assault but could not rule out self-inflicted trauma, given the resident's behavioral history. The facility's investigation included interviews with staff, review of medical records, and consultation with law enforcement. The nurse aide accused by the resident denied causing harm and reported only being scratched by the resident. The Director of Nursing and other clinical staff noted that the resident had a history of aggressive and resistive behaviors, but there was no documentation of such behaviors leading to self-injury of this severity. Law enforcement was unable to determine the cause of the injury, and the case was closed without charges. The deficiency centers on the facility's failure to protect the resident from injury of unknown origin and to ensure timely and appropriate reporting and assessment of incidents involving potential abuse or unexplained injuries.