Failure to Follow Abuse Policy for Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy in response to an injury of unknown origin involving one resident. The resident, who was dependent on staff for all activities of daily living and had diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension, was found during morning care with a small amount of blood on her pillow and a hematoma on the side of her head. The source of the injury was not observed, and the resident was unable to explain what happened. Staff interviews and witness statements revealed inconsistencies regarding who assisted with the resident's transfer and the sequence of events, with some staff unable to provide details or denying involvement. The nurse assigned to the resident did not immediately assess the injury, stating that the DON was handling the incident. Review of the facility's policy indicated that staff should immediately report all incidents and not move a resident with a suspected injury until assessed by a nurse supervisor. The policy also required documentation of the assessment, physician and representative notification, and treatment provided. In this case, the required immediate assessment and clear documentation were not completed as specified, and the incident was not managed in accordance with the established abuse policy for injuries of unknown origin.