Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident with multiple medical conditions, including osteoarthritis, lack of coordination, congestive heart failure, Alzheimer's, and dementia. The resident was admitted with moderate cognitive impairment and had a history of upper extremity impairment. On one occasion, the resident was found with multiple bruises on the right upper arm and shoulder after complaining of pain during a bed bath. Documentation showed that the nurse supervisor was notified, vital signs were taken, and attempts were made to notify the resident's representative and physician. However, there was no documentation of immediate post-incident actions, determination of the cause of the bruising, or interventions to prevent recurrence. Additionally, there was no evidence of staff interviews, physician response, or staff education related to the incident at that time. Subsequently, the resident continued to experience pain and limited range of motion in the right arm, which led to an X-ray revealing a displaced fracture of the right humerus. The facility was unable to provide a completed investigation or incident/accident form for this event. Witness statements from hospice staff indicated that the resident's shoulder had "popped" during a transfer prior to the discovery of the bruising, but there was no documentation of follow-up or assessment at that time. The facility also could not provide documentation of in-service education or training materials provided to staff following the incident. Interviews with the facility's Medical Director and Administrator confirmed that a thorough investigation should have been completed to determine the cause of the injuries and prevent recurrence. The Administrator acknowledged that education was provided to staff but was unable to produce documentation to support this claim. Overall, the facility's documentation for the resident's injury of unknown origin was incomplete for both incidents, failing to meet policy requirements for investigation, reporting, and follow-up.