Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for one resident who was found to have a subdural hematoma. According to the facility's policy, all unexplained injuries, including those of unknown source, must be investigated, even if the resident is discharged or the injury is discovered after discharge. The resident in question had a history of cognitive impairment, repeated falls, difficulty walking, and muscle wasting. The facility became aware of the subdural hematoma but did not obtain written statements from staff as part of the investigation, despite this being an expected component of a thorough inquiry. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that while staff were verbally questioned about the incident, no written documentation of their statements was collected. The NHA acknowledged that staff statements are a required part of the investigation process. Additionally, although some staff received education on falls prevention as part of a process improvement project, not all staff who worked during the relevant period had completed the training, and there was no documentation for the remaining staff. This incomplete investigation did not meet the facility's own policy requirements for responding to injuries of unknown origin.