Failure to Thoroughly Investigate Injuries of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown sources for three residents with severe cognitive impairment and high dependency for activities of daily living. In one case, a resident was found with significant bruising on her left lower arm, but the internal investigation did not include interviews with outpatient therapy staff or the resident's daughter, both of whom were present during therapy sessions. The Director of Nursing (DON) suspected the injury occurred during therapy but did not document a conclusion in the interdisciplinary team (IDT) progress notes. Another resident was discovered with a bruise on her forehead, and although the physician and family were notified and a new treatment was initiated to monitor the bruise, the investigation did not determine the cause of the injury. The resident was unable to describe the incident due to cognitive impairment, and the IDT note lacked documentation of the cause. The Administrator suspected the injury was related to the resident's broda chair, but no interventions were implemented to prevent recurrence, and the investigation's conclusion was not documented. A third resident was noted with swelling and discoloration of the left hand and wrist, later diagnosed as a fracture. The cause of the injury was unknown, and no staff or witnesses could provide an explanation. The DON suspected the injury might have occurred when the resident's hand became caught in a wheelchair wheel, but again, no conclusion was documented in the IDT progress notes. The Administrator acknowledged that investigations had not been fully completed in the past and indicated that this issue would be addressed in future quality assurance meetings.