Failure to Timely Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to timely investigate an injury of unknown origin for a resident with significant cognitive impairment and physical dependency. The resident, who had diagnoses including dementia with behavioral disturbance, malnutrition, and late-onset Alzheimer's disease, was dependent for all activities of daily living and mobility, and had interventions in place for fragile skin. A skin tear was discovered on the resident's arm during the morning shift, and while immediate wound care was provided and hospice was notified, the cause of the injury was not promptly investigated. Staff interviews revealed that the registered nurse who was informed of the injury did not ask staff present how the injury occurred and assumed it happened during a Hoyer lift transfer, but did not confirm this with those involved. Certified nursing aides involved in the transfer reported no incident during the transfer that would explain the injury and were unsure of its cause. The Director of Nursing was not informed of the injury until the following day, and the formal investigation into the incident was not initiated until several days later, after the resident's family alleged mistreatment. Documentation showed that staff statements and interviews were only obtained after the family complaint, and the incident report was not fully completed at the time of the injury. The facility's policy required an immediate investigation upon suspicion of abuse or neglect, including prompt interviews and documentation, but this was not followed. The investigation ultimately did not determine a definitive cause for the injury but found no evidence of abuse or neglect.