Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate a serious bodily injury of unknown source for one of ten sampled residents. The resident in question had multiple diagnoses, including cognitive communication deficit, vascular dementia, and required extensive assistance with activities of daily living. The resident experienced a fall that was unwitnessed, and later was found to have a right femur intertrochanteric fracture, which was discovered only after the resident was sent to the hospital for unrelated symptoms. The facility's policies required that, in the event of an injury of unknown source, interviews should be conducted with the resident, staff who provided care, other residents, and any pertinent outside sources, as well as gathering signed statements and observing the resident for behavioral clues to the injury's cause. Upon review, the investigation conducted by the facility was found to be incomplete. Only two witness statements were collected, both from department heads, and there was no evidence that direct care staff, the resident, the resident's representative, other residents, or outside sources were interviewed. There was also no documentation of observations of the resident or an evaluation of whether the resident felt safe. The investigation did not address the potential connection between the unwitnessed fall and the subsequent discovery of the fracture. Interviews with facility staff, including a Certified Medication Aide, the Unit Manager, the Director of Health Services, and the Administrator, confirmed that the standard practice was to collect statements for injuries of unknown source but not for unwitnessed falls. The Administrator, who served as the abuse coordinator, stated that the investigation was inconclusive and acknowledged that not completing a thorough investigation could result in not finding the true root cause. The documentation provided by the facility was confirmed to be the complete investigation, which lacked the required thoroughness as outlined in facility policy.