Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
This facility failed to ensure that all injuries of unknown origin were properly investigated, as required by policy. A resident with Alzheimer's disease, muscle weakness, anxiety, and adult failure to thrive, who was at risk for falls, experienced multiple injuries during their stay. The resident was admitted with moderately impaired cognition and had a care plan in place to address fall risk and safety needs. On one occasion, the resident was found with a swollen and discolored right foot and was transferred to the hospital for evaluation. Later, the same resident was noted to have facial swelling and bruising, and reported being punched in the face and having their foot stomped on. Staff documented an altercation between this resident and another, with both residents interviewed, but the investigation was limited and did not address all injuries. The administrator determined no further investigation was warranted and did not submit a self-reported incident or conduct further inquiry into subsequent injuries, including a right hand injury and a fractured pelvis. Facility policy required immediate investigation and documentation of all allegations or incidents of abuse or injury, including written statements from witnesses and involved parties. Despite this, the administrator confirmed that no investigation or report was completed for the resident's right hand injury or fractured pelvis, and the incident was not reported as required. This failure to investigate and report all injuries of unknown origin constituted a deficiency in the facility's response to alleged violations.