Failure to Obtain Complete Staff Statements in Injury Investigation
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a cognitively impaired resident who was found with fading discoloration on her left hand near the thumb and a small fading area on her left forehead. The resident, who had a history of dementia, falls, and fragile skin, was unable to recall any fall, trauma, or unusual event that could have caused the discoloration. The incident was first noticed by the resident's daughter during a visit, and the physician was informed, resulting in an x-ray order for the resident's left hand. The facility's documentation indicated that the resident was alert but confused, with a severely impaired cognition as evidenced by a BIMS score of 3 out of 15, and required staff assistance for activities of daily living. The investigation conducted by the facility included reviewing the resident's care plan, which noted interventions for skin integrity due to her fragile skin and use of protective devices such as padded siderails and arm sleeves. The facility's summary of investigation stated that statements were obtained from direct caregivers within 48 hours of the discovery of the discoloration, and no unusual occurrences were reported. However, the investigation did not include a statement from the certified nursing assistant (CNA) who was specifically assigned to the resident during the shift when the discoloration was discovered. Attempts to contact the agency that employed the CNA were unsuccessful, and the CNA did not return to work at the facility. The Director of Nursing and the Licensed Nursing Home Administrator acknowledged that the CNA's statement was important but was not obtained. Facility policy requires immediate and thorough investigation of possible abuse, neglect, or injury of unknown origin, including identifying and interviewing all involved persons and providing complete documentation. Despite this, the facility did not obtain a complete set of statements from all staff involved, particularly the CNA assigned to the resident at the time of the incident. This incomplete investigation constituted a failure to follow facility policy and regulatory requirements for investigating injuries of unknown origin in residents, especially those who are cognitively impaired and unable to provide their own account of events.