Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated for one resident who experienced an injury of unknown origin. Staff observed the resident with discoloration on the buttocks, which was later confirmed to be associated with an acute, mildly displaced comminuted right proximal femoral fracture. Despite the presence of a significant injury and the facility's policy requiring prompt and thorough investigation of injuries of unknown origin, there was no documentation or evidence that an investigation was initiated or completed to determine the cause of the injury. Multiple staff members, including CNAs, RNs, the ADON, and the DON, acknowledged that the injury was of unknown origin and recognized the importance of investigating such incidents. The DON stated that she was informed of the injury and instructed staff to notify the physician and obtain an x-ray, but did not initiate or conduct an investigation. The ADM, who was responsible for investigating injuries of unknown origin, reported not being notified of the incident until informed by surveyors and confirmed that no investigation had been conducted. The facility's own policy, revised in December 2024, required that all reports of resident abuse, neglect, and injuries of unknown source be promptly and thoroughly investigated by management. Despite this, interviews and record reviews confirmed that the required investigation did not occur, and there was no evidence to show that the facility attempted to determine how the resident sustained the injury.