Failure to Investigate Injuries of Unknown Origin and Resident Altercations
Penalty
Summary
The facility failed to conduct thorough investigations into injuries of unknown origin and a resident-to-resident altercation, affecting three residents. For one resident with severe cognitive impairment and a history of aggressive behaviors, there were two separate incidents involving significant injuries—a hand injury with a possible fracture and a head injury with hematomas and bruising. In both cases, there was no documented evidence of a formal investigation, no staff interviews, and no incident reports were submitted at the time of the injuries. The Director of Nursing and Administrator confirmed that they did not complete or document investigations, often assuming the injuries were self-inflicted due to the resident's behaviors. Another resident, also with severe cognitive impairment and a history of falls, was found with extensive bruising on the shoulder, chest, and arm, and later diagnosed with acute rib and clavicle fractures. Despite the severity and unexplained nature of these injuries, there was no documented investigation or self-reported incident filed. Staff interviews revealed that no one witnessed the events leading to the injuries, and the Director of Nursing attributed the bruising to a fall without supporting evidence or documentation of staff interviews. A third resident was involved in a physical altercation with another resident, resulting in a skin tear. The incident was documented in the medical record, but no self-reported incident was filed and no investigation was conducted. Facility policy required that all injuries of unknown origin and resident-to-resident altercations be investigated, including staff interviews and thorough documentation, but these procedures were not followed in any of the cases reviewed.