Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct complete and thorough investigations for injuries of unknown origin in six out of eight sampled residents reviewed for abuse. According to the facility's abuse policy, incident reports are required for all resident incidents, including falls, bruising, and skin tears, and each incident must be sufficiently investigated to determine the cause and include comments to prevent further injury. However, for each of the six residents cited, the facility was unable to provide documentation of any investigation accompanying the incident reports for injuries such as skin tears, hematomas, abrasions, and discoloration of unknown origin. The residents involved had significant cognitive impairments, as indicated by low BIMS scores, and multiple comorbidities such as Alzheimer's Disease, cerebral infarction, dementia, and chronic kidney disease. The incidents included findings such as a superficial skin tear, a large hematoma, a 1 cm skin tear, an abrasion, and purple discoloration, all with unknown causes. In each case, the incident was documented, but no investigation records were available to determine the cause or rule out abuse, as required by facility policy. Interviews with the DON and Administrator revealed that investigations into these incidents were either not conducted or not documented. The DON stated that discussions with staff about skin incidents are usually documented and attached to the incident report, but was unable to provide such documentation for the cited cases. The Administrator acknowledged that investigations were not routinely performed for incidents of unknown origin, often attributing injuries to resident behaviors or cognitive status without further inquiry or documentation. This lack of investigation and documentation led to the deficiency cited by surveyors.