Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. The resident, who had severe cognitive impairment and a history of Alzheimer's disease, dementia, and multiple fractures, was admitted with a surgically repaired right humerus fracture. After returning from the hospital with a cast, the resident continued to experience significant pain in the right arm, which was documented in progress notes. Despite ongoing pain and a new fracture being discovered above the previously repaired site, there was no documented investigation by the facility into how the new injury occurred. The facility's policy required immediate investigation of any physical injury of unknown source to rule out abuse, neglect, or exploitation. However, when the new fracture was identified, the facility did not initiate or document an investigation as required by their own policy. The resident was unable to communicate how the injury occurred due to severe cognitive impairment, and the Nursing Home Administrator confirmed that no investigation was conducted for the injury of unknown origin.