Failure to Thoroughly Investigate Resident Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough and timely investigation into an injury of unknown source involving a resident who was dependent on staff for all activities of daily living and had significant medical conditions, including chronic obstructive pulmonary disease and type 2 diabetes mellitus. The resident was found with a hematoma and bleeding on her head during morning care, with staff noting blood on her pillow and a bump on her head. The resident was unable to communicate what had happened, and staff provided inconsistent accounts regarding when the injury was first identified, who was present during transfers, and whether proper two-person assistance was provided during mechanical lift transfers. The facility's incident investigation was incomplete and did not adhere to its own policy, which required interviewing all relevant witnesses, including staff from prior shifts and family members who had contact with the resident. Key witness statements were missing, such as from the staff member who assisted with the transfer the previous evening and from the resident's husband, who was present the night before the injury was discovered. Additionally, the investigation did not document important details, such as the placement and condition of the Hoyer lift, or whether there was any blood on the equipment or elsewhere in the room. Staff interviews revealed confusion and lack of clarity about the events leading up to the injury, with some staff unable to confirm who assisted with transfers or whether proper procedures were followed. The facility prematurely concluded that the Hoyer lift bar caused the injury before gathering all necessary statements and evidence. The investigation was not completed within the required timeframe, and documentation was insufficient to determine the cause of the injury, resulting in a deficiency for failure to thoroughly investigate an injury of unknown origin.