Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not thoroughly investigating an injury of unknown origin for a resident with severe cognitive impairment. The resident, who required substantial assistance with bed mobility and transfers, was observed with a raised bump on the forehead and bruising on the back. Documentation showed that the resident was on alert charting and neuro checks following a reported fall, but there was no documented assessment of the forehead bruise, and the incident was not entered into the facility's incident logs. Interviews with collateral contacts revealed that the resident reported falling out of bed and being picked up by a man, but staff interviews indicated that no male staff were working at the time and that the resident was confused and cognitively impaired. Despite these reports and visible injuries, staff did not initiate an incident report or conduct a comprehensive investigation as required by facility policy and state guidelines. The staff focused on determining whether a fall had occurred rather than treating the injuries as incidents of unknown origin requiring thorough investigation. The facility's failure to promptly initiate and thoroughly conduct an investigation into the resident's injuries, as well as the lack of documentation and incident reporting, resulted in noncompliance with both facility policy and state regulations. The absence of a root cause analysis and failure to identify all contributing factors left the injuries unexplained and unaddressed according to established procedures.