Failure to Investigate Injuries of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown source for a resident with multiple complex medical conditions, including Parkinson's disease, dementia, fibromyalgia, and a history of falls. On two separate occasions, the resident sustained injuries—first noted as pain and bruising to the right lower extremity after returning from a dental appointment, and later identified as a questionable non-displaced fracture on X-ray. Despite the facility's policy requiring immediate reporting, assessment, and investigation of such injuries, there was no documented incident report or comprehensive investigation initiated by staff. Multiple staff members, including LPNs, the Assistant DON, and the DON, were aware of the resident's complaints of pain, swelling, and bruising. However, there was confusion and lack of clarity regarding the cause of the injury, with some staff assuming the injury occurred during transportation to the dentist, while others noted the resident was non-ambulatory and could not have walked as described. Documentation was inconsistent, with some staff believing others would complete necessary notes or assessments, and no clear record of a thorough assessment or investigation being completed. Interviews with staff and review of records revealed that the facility did not follow its own abuse prevention and reporting policy, which mandates investigation of all injuries of unknown origin to rule out abuse or neglect. The DON and Nursing Home Administrator both acknowledged that the injuries were of unknown source and should have been investigated, but confirmed that no such investigation took place. This lack of action resulted in a failure to ensure the resident's safety and compliance with regulatory requirements.