Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident with severe cognitive impairment and multiple complex medical conditions, including anoxic brain damage, gastrostomy and tracheostomy status, anxiety, and dysphagia. The resident was dependent on staff for all activities of daily living and had a care plan addressing skin integrity risks. On a skin evaluation, multiple scratches were noted on the resident's left arm, but the evaluation was marked incomplete and the incident report was opened in error. There was no documentation in the progress notes or physician orders regarding the scratches, and no treatment orders were initiated. Interviews with the DON and an RN revealed that the scratches were assessed, but no investigation was conducted to determine their origin, and the required documentation and reporting procedures were not followed. The facility's policy required immediate reporting and investigation of all injuries of unknown source, but this was not done. The DON confirmed that the incident met the criteria for an injury of unknown origin and acknowledged that it should have been investigated, but there was no supporting documentation or evidence of an investigation.